	<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">BM biopsy:</td><td class="gray">[Y/N]</td>
      <td class="left">WBC:</td><td class="gray">[x10<sup>9</sup>/L]</td>
    </tr>
    <tr>
      <td class="left">Sweats:</td><td class="gray">[Y/N]</td>
      <td class="left">Lymphs:</td><td class="gray">[x10<sup>9</sup>/L]</td>
    </tr>
    <tr>
      <td class="left">Fever:</td><td class="gray">[Y/N]</td>
      <td class="left">Albumin:</td><td class="gray">[g/L]</td>
    </tr>
    <tr>
      <td class="left">Wt. loss:</td><td class="gray">[Y/N]</td>
      <td class="left">&beta;<sub>2</sub>m:</td><td class="gray">[mg/L]</td>
    </tr>
    <tr>
      <td class="left">CT Scan:</td><td class="gray">[Y/N]</td>
      <td class="left">LDH:</td><td class="gray">[range]</td>
    </tr>
    <tr>
 
  <!-- CLL gets Binet + platelets, rest get Ann-Arbour -->
  [% IF case.request_report.diagnosis.icdo3.match('9823/3') %] 
    <td class="left">Binet:</td><td class="gray">[A, B, C]</td>
		<td class="left">Platelets:</td><td class="gray">[x10<sup>9</sup>/L]</td>
	[% ELSE %]
    <td class="left">Ann-Arbor:</td><td class="gray">[I - IV]</td>
		<td colspan="2">&nbsp;</td>
  [% END %]
  
	</tr>
	</table>
    
	<br style="page-break-after: always" />
    
    [% # UNLESS case.request_report.diagnosis.diagnostic_category.description.match('T-lympho') %]
  <!-- nodal/extranodal involvement tables -->
 	<p class="pid">
        [% case.patient_case.patient.last_name  | upper %],
        [% case.patient_case.patient.first_name | ucfirst %] ::
        [% INCLUDE site/lab_number.tt data = case %] ::
        [% case.patient_case.referral_source.display_name %]
    </p>
  
	<table summary="">
	<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 %]