Visit Date (Enter the date the form was completed. - Note: If the information was obtained at multiple visits, please enter the date the form was completed.)
Date of Last Dose (Enter the date of the last dose of the radiation therapy. Partial dates are acceptable when the day is not known. Leave it blank if the therapy is currently being received.)
Every 4 Hours Every Other Day, For 3 Days (q4h qod x3 days)
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Every 4 Hours (Q4HR)
CL Item
Every Four Months (q4month)
C64538 (NCI Thesaurus) C0585338 (UMLS 2011AA)
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Every 4 Months As Needed (q4month PRN)
CL Item
Every Four Weeks (q4wk)
C64529 (NCI Thesaurus) C1275555 (UMLS 2011AA)
CL Item
Every 4 Weeks As Needed (q4wk PRN)
CL Item
Every Five Days (q5d)
CL284497 (NCI Metathesaurus)
CL Item
Every 5 Days As Needed (q5d PRN)
CL Item
Every Five Hours (q5h)
CL284498 (NCI Metathesaurus)
CL Item
Every 5 Hours As Needed (q5h PRN)
CL Item
Every Five Months (q5month)
CL Item
Every 5 Months As Needed (q5month PRN)
CL Item
Every Five Weeks (q5wk)
CL Item
Every 5 Weeks As Needed (q5wk PRN)
CL Item
Every 6 To 8 Hours As Needed (q6-8h PRN)
CL Item
Every Six Days (q6d)
CL Item
Every 6 Days As Needed (q6d PRN)
CL Item
Every 6 Hours As Needed (q6h PRN)
CL Item
Every 6 Hours Every Other Day, For 3 Days (q6h qod x3 days)
CL Item
Every 6 Hours (Q6HR)
CL Item
Every Six Months (q6month)
CL263803 (NCI Metathesaurus)
CL Item
Every 6 Months As Needed (q6month PRN)
CL Item
Every Six Weeks (q6wk)
CL263800 (NCI Metathesaurus)
CL Item
Every 6 Weeks As Needed (q6wk PRN)
CL Item
Every Seven Days (q7d)
CL284509 (NCI Metathesaurus)
CL Item
Every 7 Days As Needed (q7d PRN)
CL Item
Every Seven Hours (q7h)
CL Item
Every 7 Hours As Needed (q7h PRN)
CL Item
Every Seven Weeks (q7wk)
CL Item
Every 7 Weeks As Needed (q7wk PRN)
CL Item
Every 8 Days (q8d)
CL Item
Every 8 Days As Needed (q8d PRN)
CL Item
Every 8 Hours As Needed (q8h PRN)
CL Item
Every 8 Hours (Q8HR)
CL Item
Every 8 Weeks (q8wk)
CL Item
Every 8 Weeks As Needed (q8wk PRN)
CL Item
Every 9 Days (q9d)
CL Item
Every 9 Days As Needed (q9d PRN)
CL Item
Every 9 Hours (q9h)
CL Item
Every 9 Hours As Needed (q9h PRN)
CL Item
Every Morning (qam)
CL Item
Every Morning As Needed (qam PRN)
CL Item
Every Day (qd)
CL Item
One Time A Day As Needed (qd PRN)
CL Item
Once A Day For 3 Days (qd x3)
CL Item
Every Day For 4 Days (qd x4)
CL Item
Once A Day For 5 Days (qd x5)
CL Item
Once A Day For 7 Days (qd x7)
CL Item
Every Night (qhs)
CL Item
Every Night As Needed (qhs PRN)
CL Item
Four Times A Day (qid)
CL Item
Four Times A Day As Needed (qid PRN)
CL Item
Monthly (qmonth)
CL Item
Every Month As Needed (qmonth PRN)
CL Item
Every Monday, Tuesday And Wednesday (qMTW)
CL Item
Every Monday, Wednesday And Friday (qMWF)
CL Item
Every Other Day (QOD)
CL Item
Every Other Day As Needed (qod PRN)
CL Item
Every Other Day For 3 Days (qod x3 days)
CL Item
Weekly (qwk)
CL158132 (NCI Metathesaurus)
CL Item
Every Week As Needed (qwk PRN)
CL Item
Every Week For 4 Weeks (qwk x4)
CL Item
Every Week For 8 Courses (cycles) (qwk x8 courses)
CL Item
Tapering Doses (Tapering Doses)
CL Item
Three Times A Day (tid)
CL Item
Three Times A Day As Needed (tid PRN)
CL Item
Three Times In A Day, Every Other Day (tid qod)
CL Item
Three Times A Week (TIW)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus) C0439673 (UMLS 2011AA)
CL Item
One Time (x1)
CL Item
For 1 Course (cycle) (x1 Course)
CL Item
One Time As Needed (x1 PRN)
CL Item
For 12 Courses (cycles) (x12 Courses)
CL Item
Two Times (x2)
CL Item
For 2 Courses (cycles) (x2 Courses)
CL Item
Two Times As Needed (x2 PRN)
CL Item
Three Times (x3)
CL Item
For 3 Courses (cycles) (x3 Courses)
CL Item
Three Times As Needed (x3 PRN)
CL Item
Four Times (x4)
CL Item
For 4 Courses (cycles) (x4 Courses)
CL Item
Four Times As Needed (x4 PRN)
CL Item
Five Times (x5)
CL Item
For 5 Courses (cycles) (x5 Courses)
CL Item
Five Times As Needed (x5 PRN)
CL Item
For 6 Courses (cycles) (x6 Courses)
CL Item
For 8 Courses (cycles) (x8 Courses)
CL Item
For 8 Days (x8 days)
RTAdministeredTotalDose
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Total Dose (State the total radiation dose the patient received during the treatment period. Leave this field as well as the Total Dose UOM blank if the radiation therapy is ongoing.)