	<table summary="" class="data">
	<tr>
      <td class="left">ECOG:</td><td class="short">[0 - 4]</td>
      <td class="left">Hb:</td><td class="short">[g/dL]</td>
    </tr>
    <tr>
      <td class="left">WBC:</td><td class="gray">[x10<sup>9</sup>/L]</td>
	  <td class="left">Platelets:</td><td class="gray">[x10<sup>9</sup>/L]</td>
    </tr>
    <tr>
      <td class="left">PCV:</td><td class="gray">%</td>
      <td class="left">Neutrophils:</td><td class="gray">[x10<sup>9</sup>/L]</td>
    </tr>
    <tr>
      <td class="left">Lymphocytes:</td><td class="gray">[x10<sup>9</sup>/L]</td>
      <td class="left">Monocytes:</td><td class="gray">[x10<sup>9</sup>/L]</td>
	</tr>
	</table>

    <h4>Comments:</h4>
