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Pelvis GYN HDR – Triple Tandem Sim Directive (30 min) Projected # Treatments: 3 or Projected Dose per fraction: 5 Gy or Required MRI Date: MRI Date: Series # Series # Scheduling/Authorization Approval Simulations will not be scheduled unless filled out Stage: ECOG status: Choose Treatment method: HDR Total Gy: # Fractions: Pre Simulation: Insert Foley catheter and inject with 7cc contrast. Physician place packing before scout image or Patient Immobilization: Light blue pad or Pillow or Arms on chest or Legs straight or Scan Parameters: Superior border at L3/L4 interspace or Inferior border ischial tuberosity/introitus or Slice thickness: 1 mm slices (at least through tip of tandems) or Set kVp to 140 CT reference point 2 cm superior of umbilicus or Additional Simulation Instructions: (e.g., placement of wires, markers, BB’s etc.) Verify that Foley has been tugged Verify that contrast has been injected into Foley (at least for first fraction) Verify tandem tips and orientation. Verify that the tandem necks are even on scout, and print for comparison. Once scan has been approved, mark levels and lateral lasers for ease of repositioning during verification scans. Page Physics Attending Resident to check CT scan Simulation Directive Completed By: <Entered By> <Current Date> Simulation Note: I was present to Choose Attending Signature: <Approved By> <Approved date time> Electronically signed by controlled access password Copyright * 2008 The Regents of The University of Michigan