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            <td align="center" class="FormInsideTableTopCell"><strong>Present</strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Disease<br>
              Related</strong></td>
            <td width="50%" align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableLeftCell">General</td>
            <td align="left" class="FormInsideTableRegCell">Fever</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Weight Loss</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableLeftCell">Neuro</td>
            <td align="left" class="FormInsideTableRegCell">Headaches</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Focal Weakness</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">Eyes</td>
            <td align="left" class="FormInsideTableRegCell">Visual Problems</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableLeftCell">CV</td>
            <td align="left" class="FormInsideTableRegCell">Angina</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Palpitations</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">Respiratory</td>
            <td align="left" class="FormInsideTableRegCell">Cough</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">SOB</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Hemoptysis</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="4" align="left" valign="top" class="FormInsideTableLeftCell">GI</td>
            <td align="left" class="FormInsideTableRegCell">Nausea</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="4" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Vomiting</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Abdominal Pain</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Rectal Bleeding</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp; </td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">GU</td>
            <td align="left" class="FormInsideTableRegCell">Dysuria</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Frequency</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Incontinence</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">MS</td>
            <td align="left" class="FormInsideTableRegCell">Joint Pain</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">Psych</td>
            <td align="left" class="FormInsideTableRegCell">Anxiety / Depression</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableLeftCell">Heme</td>
            <td align="left" class="FormInsideTableRegCell">Anemia</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Adenopathy</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">Skin</td>
            <td align="left" class="FormInsideTableRegCell">Rash</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">Endo</td>
            <td align="left" class="FormInsideTableRegCell">Heat/Cold Intolerance</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Thirst</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Hot Flashes</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td colspan="7" align="left" valign="top">Other:</td>
          </tr>
        </table></td>
    </tr>
    <tr bgcolor="#FFFFFF"> 
      <td height="25" class="FormOuterTableRow">&nbsp; 
        <input name="HistoryROSReview" type="checkbox" id="HistoryROSReview" value="Yes">
        <span class="blackBoldText"> PFSH and ROS performed by: _____________________________________ 
        &nbsp;&nbsp;&nbsp;&nbsp;Date: ____/____/____ </span></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">3</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>
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