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<td height="14" align="center" valign="bottom" class="blackBoldText">GU12<img src="../../Images/shim.gif" border="0" width="45" height="1">U16<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">6</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">12</span></td>
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</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">*U16*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
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<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
New 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="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td height="60" valign="top" class="FormOuterTableRow"><table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td align="left" valign="top" height="110"><img src="../../Images/shim.gif" border="0" width="4" height="0" /><span class="blackBoldText">Comorbidities</span></td>
<td width="400" align="right" valign="top"><table width="400" border="0" cellspacing="0" cellpadding="0">
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="10" height="5" /></td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Coronary Artery Disease / MI<br/>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Other Cardiac Disease __________<br/>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Hypertension<br/>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> CVA<br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Thromboembolic Events / DVT<br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Pulmonary Disease / Asthma / COPD<br/> </td>
<td valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Diabetes (IDDM/NIDDM)<br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Hypercholesterolemia<br/>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Depression<br/>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Back Pain / DJD <br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Nephrolithiasis<br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Renal Insufficiency </td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td height="80" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15" /><span class="blackBoldText">Medical
& Surgical History</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table border="0" width="650" cellpadding="2" cellspacing="0">
<tr align="left">
<td colspan="6" valign="middle"><span class="blackBoldText">Presenting
Symptoms<img src="../../Images/shim.gif" border="0" width="30" height="1" />
<input type="checkbox" name="No2222" />
Incidental</span></td>
</tr>
<tr>
<td width="70" align="center" valign="middle" class="FormInsideTableTopCell">System</td>
<td width="120" align="center" valign="middle" class="FormInsideTableTopCell">Symptom</td>
<td width="70" align="center" valign="middle" class="FormInsideTableTopCell">Not
Present</td>
<td width="50" align="center" valign="middle" class="FormInsideTableTopCell">Present </td>
<td width="80" align="center" valign="middle" class="FormInsideTableTopCell">Present
Now </td>
<td width="260" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
</tr>
<tr>
<td rowspan="4" align="center" valign="top" class="FormInsideTableRegCell">GU</td>
<td class="FormInsideTableRegCell">Flank 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" vspace="1" /></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell">Hematuria</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell">Flank Mass</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell">Iritative Voiding</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="3" align="center" valign="top" class="FormInsideTableRegCell">Gen</td>
<td 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" vspace="1" /></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell">Malaise</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell">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" vspace="1" /></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" class="FormInsideTableRegCell">C/V</td>
<td class="FormInsideTableRegCell">Cardio-Respiratory</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" class="FormInsideTableRegCell">M/S</td>
<td class="FormInsideTableRegCell">Neuro-Muscular</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="25" colspan="6" class="FormInsideTableRegCell"> Other</td>
</tr>
<!---<tr class="eFormInnerTableRow">
<td height="18"> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>--->
</table>
*hesitancy, intermittance, weak stream, dribbling</td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU12<img src="../../Images/shim.gif" border="0" width="45" height="1">U16<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">2</span> of <span id="TotalPages">6</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">12</span></td>
</tr>
</table>
</div>
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