<table summary="" class="data">
<tr>
<td class="left">Splenomegaly:</td><td class="short">[Y/N]</td>
<td class="left">Detection:</td><td class="long"> </td>
</tr>
<tr>
<td class="left">Hepatomegaly:</td><td class="gray">[Y/N]</td>
<td class="left">Detection:</td><td class="gray"> </td>
</tr>
<tr>
<td class="left">ECOG:</td><td class="short">[0 - 4]</td>
<td class="left">Lymphocytes:</td><td class="gray">[x10<sup>9</sup>/L]</td>
</tr>
<tr>
<td class="left">WBC:</td><td class="gray">[x10<sup>9</sup>/L]</td>
<td class="left">Neutrophils:</td><td class="gray">[x10<sup>9</sup>/L]</td>
</tr>
<tr>
<td class="left">Hb:</td><td class="short">[g/dL]</td>
<td class="left">Monocytes:</td><td class="gray">[x10<sup>9</sup>/L]</td>
</tr>
<tr>
<td class="left">PCV:</td><td class="gray">[%]</td>
<td class="left">Platelets:</td><td class="gray">[x10<sup>9</sup>/L]</td>
</tr>
<tr>
<td class="left">Haematocrit vol:</td><td class="gray">%</td>
<td class="left"></td><td class="gray"></td>
</tr>
<tr>
<td class="left">Erythropoietin:</td><td class="gray">[range]</td>
<td class="left"></td><td class="gray"></td>
</tr>
</table>
<h4>Comments:</h4>