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<!-- BEGIN [% component.name %] -->
	<table class="indent">
	<tr>
	<td>
		<h4>Nodal involvement:</h4>
		<table summary="" class="data">
			<tr>
				<th>Site</th> <th>L | R</th>
			</tr>
			<tr>
				<td class="left">Waldeyer's ring:</td>
        <td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Neck:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Infraclavicular:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Axillary/pectoral:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Arm:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Thymus:</td><td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Hilar:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Mediastinal:</td>
        <td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Para-aortic:</td>
        <td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Spleen:</td>
        <td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Mesenteric:</td>
				<td align="center"><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Iliac:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Inguinal/femoral:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Popliteal:</td>
				<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
			</tr> 
			<tr>
				<td class="left">Bulky disease:</td>
        <td align="center"><input type="checkbox" /></td>
			</tr> 
		</table>
	</td>
	<td>
		<h4>Extranodal involvement:</h4>
		<table summary="" class="data">
		<tr>
			<th>Site</th><th>L | R</th>
		</tr>
		<tr>
			<td class="left">Blood:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Bone:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">CNS:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">GIT:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">GU:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Liver:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Marrow:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Muscle:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Orbit:</td>
      <td align="center"><input type="checkbox" /><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Pericardium:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Pulmonary:</td>
      <td align="center"><input type="checkbox" /><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Salivary gland:</td>
			<td align="center"><input type="checkbox" /><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Skin:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Thyroid:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		<tr>
			<td class="left">Other:</td>
      <td>&nbsp;</td>
		</tr> 
		<tr>
			<td class="left">Extensive disease:</td>
      <td align="center"><input type="checkbox" /></td>
		</tr> 
		</table>
	</td>
  </tr>
 </table>
<!-- END [% component.name %] -->