Ultimate Cancer Treatment

Proton Therapy

Southern TOHOKU Proton Therapy Center

172-7choume,Yatsuyamada,Koriyama,Fukushima 963-8563 JAPAN

 
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>>Contact Information of Physician

*Salutation
*Acad.Degree
*First Name   Middle Initial  Last Name 
*Med. Institute
(Hospital, Cancer Center, Clinic etc. )
*Department
*Street Address
*City       *State/Province 
*Zip/Postal     *Country 
*Daytime Phone       *Evening Phone 
*Cell Phone
*E-mail    *E-mail to confirm 

>>Diagnoeis & Treatment Information (Patient Information)

*Patients Name Initial
*Male / Female
*Age
*Pathology
(Primary Cancer Diagnosis )
*TNM
(UICC 2002)		 T_ N_ M_ Stage_
*Fresh/Recurrence
*Complication   If Yes, e.x.) Hypertension, Diabetesmellitus
*Previous treatment Yes No
*If Yes, which treatment method ? Select Treatment Method
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  
*Currently treatment Yes No
*If Yes, which treatment method ? Select Treatment Method
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  
*An episode of the illness or coments
   

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