Palliative Planing

• Document No.

• Date of contour

  Date

• Treatment site Age Gender

• Attending

  Select Brundage de Metz Falkson Kalyvas Mahmud Thain Zaza Owen Shenfield Others

  • Brundage
  • de Metz
  • Falkson
  • Kalyvas
  • Mahmud
  • Thain
  • Zaza
  • Owen
  • Shenfield
  • Others

• CR

• ID

  Media
• Location
  Address

• Date of record

  Date

• Diagnosis

  Select Prostate Breast Lung Endometrial Cervical Bladder Testicular Primary CNS Lymphoma Esophageal Gastric Colon Head &Neck Skin Sarcoma Other

  • Prostate
  • Breast
  • Lung
  • Endometrial
  • Cervical
  • Bladder
  • Testicular
  • Primary CNS
  • Lymphoma
  • Esophageal
  • Gastric
  • Colon
  • Head &Neck
  • Skin
  • Sarcoma
  • Other

• Extend of disease

  Select Brain Spine Chest Abdomen Pelvis Extremity

  • Brain
  • Spine
  • Chest
  • Abdomen
  • Pelvis
  • Extremity

• Previous radiation

  No

  Yes

  Unknown

• Clinical history

Radiation Therapy

• Site of radiation

  Select Brain Spine Chest Abdomen Pelvis Extremity

  • Brain
  • Spine
  • Chest
  • Abdomen
  • Pelvis
  • Extremity

• Dose

  20Gy/5

  8Gy/1

  Other

• Gy/fractions

Contour

• Note 1

• Review

• Screenshot

  Media

• Illustration

  Drawing

• Amount of time used in hrs.