Primary Central Nervous System (CNS)
Neoplasm Radiation Therapy
(As of 17 April 2018)
This worksheet is to be used for curative or palliative treatment of primary central nervous system neoplasm.
What is the radiation therapy treatment start date (mm/dd/yyyy)? ______ /______ /______
What is the patient’s WHO grade or diagnosis?
I: Pilocytic astrocytoma
II: Low grade oligo/ astrocytoma/ependymoma
III: Anaplastic astrocytoma
IV: Glioblastoma multiform (GBM)
Primary spinal tumor
Recurrent primary CNS malignant tumor previously irradiated
Supratentorial PNET (primitive neuroectodermal tumor)
Benign: Meningioma, Schwannoma, Pituitary Adenoma
2. What is the
Fully active, able to carry on all pre-disease performance without restriction
Restricted in physically strenuous activity but ambulatory and able to carry out
work of a light or sedentary nature, e.g., light house work, office work
Ambulatory and capable of all self-care but unable to carry out any work
activities. Up and about more than 50% of waking hours.
Capable of only limited self-care, confined to bed or chair more than 50% of
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
What resection has been performed?
Gross total resection
Continued on next page