IROC HOUSTON'S EXTERNAL BEAM DOSIMETRY SUMMARY FORM

Institution Name:*    
Physicist/Dosimetrist First Name:*     Last Name:*  
Physicist/Dosimetrist e-mail address:*    
Radiation Oncologist First Name:*     Last Name:*  
Radiation Oncologist e-mail address:*    
Protocol #:*   RTF#(look up here):*   RTOG NSABP GOG NCCTG ANZGOG TACO    
Case #*   Patient initials:*    
DOSE PRESCRIPTION
Please complete a new external beam dosimetry form for each prescription (i.e. pelvic script, boost script,extended field script, etc...)
Dose Prescription:*   cGy, Number of Fractions*      
Treatment Machine Model & SN*    
Radiation Therapy Start Date:   Radiation Therapy End Date:    
TREATMENT TECHNIQUE
  Field 1
Field Name*
(ANT, POST,  RT LAT, etc.)
 
Energy*(e.g. 6X)  
SSD*  
Gantry angle
Collimator angle
Couch Angle
Collimator Setting*
(WxL  if using independent
jaws X1,X2,Y1,Y2) in cm
W   L  
X1 X2
Y1 Y2
Effective Blocked Field Size*   
Depth of Prescription
Point(actual)*
  
Depth of Prescription
Point(effective)*
  
Off-Axis(Distance/Factor)
/
Attenuators: Block or Tray
factor
wedge type
Physical
Internal
Enhanced Dynamic
Virtual
wedge angle/factor
/
Compensator
(factor/material/ thickness)
/ /
Bolus depth(cm)
Dose per Fraction*  
Monitor Units per fraction*  

To complete additional fields please click "Next" button

  Next
Field 2
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 2
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Next Cancel
Field 3
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 3
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Next Cancel
Field 4
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 4
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Next Cancel
 
  Field 5
Field Name*
(ANT, POST,  RT LAT, etc.)
Energy*(e.g. 6X)
SSD*
Gantry angle
Collimator angle
Couch Angle
Collimator Setting*
(WxL  if using independent
jaws X1,X2,Y1,Y2) in cm
W L
X1 X2
Y1 Y2
Effective Blocked Field Size*
Depth of Prescription Point(actual)*
Depth of Prescription Point(effective)*
Off-Axis(Distance/Factor)
/
Attenuators: Block or Tray
factor
wedge type
Physical
Internal
Enhanced Dynamic
Virtual
wedge angle/factor
/
Compensator
(factor/material/ thickness)
/ /
Bolus depth(cm)
Dose per Fraction
Monitor Units per fraction
 
 
  Field 5
Field Name*
(ANT, POST,  RT LAT, etc.)
Energy*(e.g. 6X)
SSD*
Gantry angle
Collimator angle
Couch Angle
Collimator Setting*
(WxL  if using independent
jaws X1,X2,Y1,Y2) in cm
W L
X1 X2
Y1 Y2
Effective Blocked Field Size*
Depth of Prescription Point(actual)*
Depth of Prescription Point(effective)*
Off-Axis(Distance/Factor)
/
Attenuators: Block or Tray
factor
wedge type
Physical
Internal
Enhanced Dynamic
Virtual
wedge angle/factor
/
Compensator
(factor/material/ thickness)
/ /
Bolus depth(cm)
Dose per Fraction
Monitor Units per fraction
 
  Next Cancel
Field 6
W L  
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 6
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Next Cancel
Field 7
W L  
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 7
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Next Cancel
Field 8
W L  
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
Field 8
W L
X1 X2
Y1 Y2
/
Physical
Internal
Enhanced Dynamic
Virtual
/
/ /
  Cancel

* This is a required field.