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</table></td>
<td width="315"> <table width="315" border="0" cellspacing="0" cellpadding="4">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Allergies</span> <span>
<input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">
NKA
<input name="DateLastGnRH3" type="checkbox" id="DateLastGnRH3" value="yes">
Unchanged Since Last Visit</span></td>
</tr>
<tr align="center">
<td width="150" class="FormInsideTableRegCell">Allergen</td>
<td width="165" class="FormInnerRowBottomBorder">Reaction</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
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<td class="FormInsideTableRegCell"> </td>
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<td class="FormInnerRowRightBorder"> </td>
<td> </td>
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</table></td>
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</table></td>
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<tr>
<td height="70" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Comorbidities</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Disease
State</span><img src="../../Images/shim.gif" border="0" width="26" height="1">
<input type="checkbox" name="NED2">
NED<img src="../../Images/shim.gif" border="0" width="26" height="1"> <input type="checkbox" name="LCR2">
LCR<img src="../../Images/shim.gif" border="0" width="20" height="1"> <input type="checkbox" name="LCR22">
Urothelial<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="LCR23">
Upper Tract<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="LCR232">
Bladder<br> <img src="../../Images/shim.gif" border="0" width="112" height="1">
<input type="checkbox" name="Mets2">
Mets<img src="../../Images/shim.gif" border="0" width="20" height="1">Date:</td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU13<img src="../../Images/shim.gif" border="0" width="45" height="1">U17<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:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">1</span> of <span id="TotalPages">5</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">13</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">*U17*</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 Upper Tract Urothelial
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>
<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 height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="510" colspan="3"><span class="blackBoldText">Lab Tests</span> Date:
______________ Data Source:_______________</td>
</tr>
<tr>
<td colspan="3"><img src="../../Images/standardLabsGridLined.gif" width="642" height="98"></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Addtional
Lab Tests</span><br> <table align="center" border="0" width="650" cellpadding="2" cellspacing="0">
<tr>
<td width="80" align="center" class="FormInsideTableTopCell">Date</td>
<td width="80" align="center" class="FormInsideTableTopCell">Test</td>
<td width="80" align="center" class="FormInsideTableTopCell">Result</td>
<td width="80" align="center" class="FormInsideTableTopCell">Data Source</td>
<td width="6" align="center" class="FormInnerRowRightBorder"> </td>
<td width="80" align="center" class="FormInsideTableTopCell">Date</td>
<td width="80" align="center" class="FormInsideTableTopCell">Test</td>
<td width="80" align="center" class="FormInsideTableTopCell">Result</td>
<td width="80" align="center" class="FormInsideTableTopCell">Data Source</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInnerRowRightBorder"> </td>
<td height="12" class="FormInnerRowRightBorder"> </td>
<td height="12" class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td> </td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Imaging</span><span><img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Films Reviewed">
Films Reviewed<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Compared to Past">
Compared to Past<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Reviewed with Radiologist">
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