RADIOLOGICAL PHYSICS CENTER DOSIMETRY SUMMARY
Institution:
RTF#:
Physicist/Dosimetrist:
First Name:
Last Name:
Radiation Oncologist:
First Name:
Last Name:
Contact e-mail:
phone #:
DOSE PRESCRIPTION
Number of Fractions
Total Dose to Prescription Point
cGy
Treatment Machine Model
Reference Case
Brain
Breast
Craniospinal
Mantle
TREATMENT TECHNIQUE
Field 1
Field 2
Field 3
Field 4
Field 5
Field 6
Field Name (ANT, POST, RT LAT, etc.)
Energy (e.g. 6X)
SSD
Gantry / Collimator / Couch Angle
/
/
/
/
/
/
/
/
/
/
/
/
Collimator Setting (WxL or if using independent jaws X
1
, X
2
, Y
1
, Y
2
) in cm
x
X
1
X
2
Y
1
Y
2
x
X
1
X
2
Y
1
Y
2
x
X
1
X
2
Y
1
Y
2
x
X
1
X
2
Y
1
Y
2
x
X
1
X
2
Y
1
Y
2
x
X
1
X
2
Y
1
Y
2
Effective Blocked Field Size
Eff.Depth of Prescription Point
Off-Axis (Distance/Factor)
cm/
cm/
cm/
cm/
cm/
cm/
Mediastinum Eff field size /
Eff SSD / Eff depth / OAD
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Supraclavicular Eff field size / Eff SSD / Eff depth / OAD
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Attenuators: Block or Tray Factor if applicable
Wedge (angle/factor)
Physical
Internal
Enhanced Dynamic
Virtual
/
/
/
/
/
/
Compensator (factor, material, thickness) / Bolus (depth)
Dose per Fraction
Monitor Units per Fraction