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:   Ohter
*Name First Name:   Middle Initial  Last Name 
*Medical. 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: 
*Purpose:

>>Diagnoeis & Treatment Information (Patient Information)

*Patients Name:  First Name   Middle Initial  Last Name 
*Male / Female:
*Date of Birth:  Year   Month  Date  Age 
*Nationality:   *Language: 
*Medical Institute he/she currently visit:  
*Chief Doctor:  
*Clinical Diagnosis:  
*Pathology:
(Primary Cancer Diagnosis )
*TNM:
(UICC 2002) T_ N_ M_ Stage_
*Fresh/Recurrence:
*Complication:    If Yes, e.x.) Hypertension, Diabetesmellitus
*Previous History(An episode of the illness or comments)
*Chief Complaint:

*Previous Treatment:
Yes No
If Yes, which treatment method ? Select Treatment Method
(1): Month   Year  ~ Month   Year 
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  

(2): Month   Year  ~ Month   Year 
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  

(3): Month   Year  ~ Month   Year 
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  

*Currently Status

*Comment

*Currently Treatment
Yes No
*If Yes, which treatment method ? Select Treatment Method
Month   Year  ~ Today  
Surgery RadioTherapy Chemmotherapy HormoneTherapy
other  
*General Health Condition  

*Inquiry or question tu us:
*If you have any key images e.x.) MRI,CT or PET-CT,please attache some images.
Attention! The limit of the image total volume is 3MB.

Please send us previous MRI,CT or PET-CT images of the patient in CD with DICOM-format
not compressend by Post to the address below.

The International Medical Center
Southern Tohoku Group
7-115 Yatsuyamada,Koriyama-city,Fukushima-Pref.
963-8563 JAPAN

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