669 / 1332
Infiltrativ
e
Exophytic
Cervix
Vagina
Parametria
Rectum or
Bladder
At Diagnosis □ / At Brachytherapy □
[Brachytherapy fraction no. __]
h
= ____ cm
t
= ____ cm
w
= ____ cm NMD (R) =____cm NMD (L) =____cm
w
5 4 3 2 1 -1 -2 -3 -4
-5
5
4
3
2
1
-
1
-
2
-
3
-
4
-
5
[NMD-Near Minimum Distance]
Vaginal Disease
Ant : ___ cm
Post :___ cm
Rt Lat: ___cm
Lt Lat: ___cm
12
1
2
3
4
5
7
11
6
10
8
9
Anterior
Posterior
w
NMD(L)
NMD(R)
5 4 3 2 1 0 -1 -2 -3 -4 -5
1
2
3
4
6
5
7