	[% # set some accessors:
        patient = case.patient_case.patient;
        report  = case.request_report;
    %]

    <p style="page-break-before: [% loop.first ? 'avoid' : 'always' %]" class="header">
        HMRN Data Collection: [% report.diagnosis.name %] [[% report.diagnosis.icdo3 %]]
    </p>
	<p>
        <b>Please enter data into boxes, and amend any incorrect or missing details:</b>
    </p>

	<table summary="" class="pid" align="center">
        <tr>
            <td class="left" width="25%">Patient Name:</td>
            <td class="right">
                [% patient.last_name  | upper %],
                [% patient.first_name | ucfirst %]
            </td>
            <td class="left" width="25%">HILIS ID:</td>
            <td class="right">[% case.patient_case.patient_id %]</td>
        </tr>
        <tr>
      [% IF patient.dob %]
          <td class="left">Date of Birth:</td>
          <td class="right">[% patient.dob.strftime('%d.%b.%Y') %]</td>
      [% ELSE %]
           <td class="left"><span class="red">Date of Birth: </span></td>
           <td class="right">&nbsp;</td>
      [% END %]

      [% IF patient.nhs_number %]
          <td class="left">NHS No:</td>
          <td class="right">
            [% PROCESS site/nhs_number.tt nhs_number = patient.nhs_number %]
          </td>
      [% ELSE %]
           <td class="left"><span class="red">NHSNo:</span></td>
           <td class="right">&nbsp;<span class="gray">
                [PatNo: [% case.patient_case.unit_number %]]</span>
           </td>
      [% END %]
        <tr>
            <td class="left">HMDS Number:</td>
            <td class="right">
                [% INCLUDE site/lab_number.tt data = case %]
            </td>
            <td class="left">Report Date:</td>
            <td class="right">
                [% authorisation_date.strftime('%d.%b.%Y') %]
            </td>
        </tr>
        <tr>
            <td class="left">Source:</td>
            <td class="right">
                [% case.patient_case.referral_source.display_name %]
                [[% case.referrer_department.referrer.name %]]
            </td>
            <td class="left">Specimen:</td>
            <td class="right">
                [% specimen_map.item(case.id).sample_code.join(', ') %]
            </td>
        </tr>
	</table>

	<hr noshade />

	<div class="datacontainer">
		<div class="datatitle">

			Demographics:

		</div>
		<div class="datacontent">

	<table summary="" class="data">
        <tr>
            <td class="left">Gender:</td>
					<td class='gray' align="center">
                        &nbsp;&nbsp;M&nbsp;&nbsp;/&nbsp;&nbsp;F&nbsp;&nbsp;
                    </td>
            <td class="left">Date of diagnosis:</td>
            <td width="20%">&nbsp;</td>
        </tr>
        <tr>
            <td class="left">Address at diagnosis:</td>
            <td colspan="3" class="address">&nbsp;</td>
        </tr>

        <tr>
            <td class="left">GP address:</td>
            <td colspan="3" class="gp">&nbsp;</td>
        </tr>
        <tr>
            <td class="left">1st&nbsp;appointment&nbsp;on:</td>
            <td>&nbsp;</td>
            <td class="left">Palliative date:</td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td class="left">Date of death:</td>
            <td>&nbsp;</td>
            <td colspan="2">&nbsp;</td>
        </tr>
	</table>

		</div>
	</div>

	<div class="datacontainer">
		<div class="datatitle">

			Antecedent / concurrent events:

		</div>
		<div class="datacontent">

	<table summary="" class="data">
        <tr>
            <td class="left">Event:</td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td class="left">Therapies:</td>
					<td class='gray' >
                    &nbsp;&nbsp;chemotherapy&nbsp;&nbsp;/&nbsp;&nbsp;radiotherapy
                    &nbsp;&nbsp;/&nbsp;&nbsp;both&nbsp;&nbsp;
            </td>
        </tr>
	</table>

		</div>
	</div>

	<div class="datacontainer">
		<div class="datatitle">

			Treatment history:

		</div>
		<div class="datacontent">

	<table summary="" class="data">
        <tr>
            <td class="left">Centre:</td>
            <td class='gray' colspan="2" width="400">[name]</td>
        </tr>
        <tr>
            <td class="left">Treatment:</td>
            <td class='gray' colspan="2" width="400">[treatment name]</td>
        </tr>
        <tr>
            <td class="left">Trial:</td>
            <td class='gray' colspan="2" width="400">[trial name]</td>
        </tr>
	</table>

	<table summary="" class="data" width="496">
        <tr>
            <td class="left">Start date:</td>
            <td width="15%">&nbsp;</td>
            <td class="left">End date:</td>
            <td width="15%">&nbsp;</td>
            <td class="left">Response:</td>
            <td width="15%">&nbsp;</td>
        </tr>
	</table>

		</div>
	</div>
