Institution
Item
Institution
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name
text
Patient'sI.D.No.
Item
Patient's I.D. No.
text
AnatomicalTreatmentArea
Item
Anatomical Treatment Area (DAILY DOSE CALCULATIONS)
text
Fieldprojection
Item
Field projection (ant, lat, oblique, etc.)
text
Manufacturernameandunitenergy
Item
Manufacturer name and unit energy
text
Monitorunits/minutes
Item
Monitor units/minutes
text
Tumordoseperfieldforeachfield@pointofprotocolprescription
Item
Tumor dose per field for each field @ point of protocol prescription
text
Item
SSD/SAD (circle one)
text
Code List
SSD/SAD (circle one)
Item
SSD/SAD (circle one)
text
Code List
SSD/SAD (circle one)
Treatmentdepth
Item
Treatment depth (cm)
text
Collimatorsetting
Item
Collimator setting (Field size in cm at isocenter)
text
EquivalentsquareatSSD/SAD
Item
Equivalent square at SSD/SAD
text
CGY/MU(Linac)
Item
CGY/MU (Linac)
text
CGY/MIN(cobalt)
Item
CGY/MIN (cobalt)
text
Other,specify(transmissionfactors)
Item
Other, specify (transmission factors)
text
Other,specify(transmissionfactors)
Item
Other, specify (transmission factors)
text
%DD,TAR,TMR,TPR,TOR
Item
% DD, TAR, TMR, TPR, TOR
text
Item
% DD, TAR, TMR, TPR, TOR
text
Code List
% DD, TAR, TMR, TPR, TOR
Formcompletedby
Item
Form completed by
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)