	<table summary="" class="data">
        <tr>
            <td class="left">Splenomegaly:</td><td class="short">[Y/N]</td>
            <td class="left">Detection:</td><td class="long">&nbsp;</td>
        </tr>
        <tr>
            <td class="left">Hepatomegaly:</td><td class="gray">[Y/N]</td>
            <td class="left">Detection:</td><td class="gray">&nbsp;</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">[&#37;]</td>
			<td class="left">Platelets:</td><td class="gray">[x10<sup>9</sup>/L]</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>
