Patient Treatment Diary - PDF Free Download

Human Normal Immunoglobulin (165 mg/ml) For Subcutaneous Human Normal Immunoglobulin (165 mg/ml) for subcutaneous infusion Patient Treatment Diary

Human Normal Immunoglobulin (165 mg/ml) For Subcutaneous Patient Treatment Diary This gammanorm treatment diary has been especially designed to help you record details of your treament now that the product has been prescribed by your doctor. A healthcare professional will have already provided you with appropriate training on how to administer gammanorm and they will have also checked that you understand and are proficient in the required techniques; however, should have you any further concerns or questions please call your healthcare professional for more information. In this diary you should record your treatments, how you feel before, during and after each treatment and any other medications you have taken. All side effects should be recorded and reported to your doctor whether or not you think they might be related to your treatment. The information you record in this diary is an important tool for both you and your doctor to monitor and evaluate your on-going health and treatment. This diary should accompany you to all visits to your doctor so that any changes to your treatment can be accurately recorded. Some blank pages for notes/comments have also been included at the back of your diary should you want to record any additional information or to write down questions that you might want to ask your doctor at your next visit. On page 6 of this diary you can find an example of how to enter information into the diary such as the batch number, volume, infusion sites used and potential side effects. This gammanorm therapy diary belongs to: Name: 2 Phone: Hospital/Clinic: Name of treating doctor: Phone number of treating doctor:

Healthcare Professional Contact Details: Doctor/Specialist s Name: Hospital/Clinic: Phone: Doctor/Specialist s Name: Hospital/Clinic: Phone: Nurse Consultant Name: Hospital/Clinic: Phone: Nurse Consultant Name: Hospital/Clinic: Phone: General Practitioner Name: Clinic: Phone: Important Phone Numbers: Name and Contact Number for Issues/Questions Related to your Medicine and/or Supplies: Phone: Name and Contact Number for Pump Issues/Questions: Phone: 3

Human Normal Immunoglobulin (165 mg/ml) For Subcutaneous Patient Treatment Diary Your Information: Please note that the dose and infusion rate of gammanorm as advised below has been worked out specifically for you by your doctor. Please follow this advice and do not change infusion rates prior to consulting with your doctor. dose of gammanorm per infusion: (grams) or (mls) rate (mls/hr): Number of injection sites to be used at each infusion: to be per site (mls): site(s): refer to the for sites to be used Number of infusions per week: : Signature of Doctor: 5 1 4 3 2 6 site(s): (circle appropriate site(s) to be used) 4

Changes to Your Information Changed: dose of gammanorm per infusion: (grams) or (mls) rate (mls/hr): Number of injection sites to be used at each infusion: to be per site (mls): site(s): refer to the for sites to be used Number of infusions per week: : 1 4 3 2 Signature of Doctor: 5 6 site(s): (circle appropriate site(s) to be used) 5

gammanorm Treatment Diary Name of Medication Product Collected from the Hospital Number of Vials Vials Collected of Vials (i.e. 10mL or 20mL) April 2013 Monthly Reconciliation Record Month Year Number of Reason for gammanorm 2 Feb 2013 10 all 20mL 1 wasted vial Accidentally dropped & broke vial Monthly Record : 1 AywwXzzz1y 40ml 1, 2 1hr runny nose none

Monthly Record : 8 AywwXzzz1y 40ml 1, 2 1hr runny nose none : 15 AywwXzzz1y 40ml 3, 4 1hr 5min pain at infusion site panadol : 22 AywwXzzz1y 40ml 1, 2 1hr 10min

gammanorm Treatment Diary Monthly Reconciliation Record Month Year Name of Medication Product Collected from the Hospital Number of Vials Vials Collected of Vials (i.e. 10mL or 20mL) Number of Reason for Monthly Record

Monthly Record

Notes/Comments

For further information about your treatment or medical condition, please contact your healthcare professional Octapharma Australia Pty Ltd ABN: 23 109 574 692 Jones Bay Wharf 42/26-32 Pirrama Road Pyrmont NSW 2009 Tel: 02 8572 5800 Fax: 02 8572 5890 Medical Enquiries: 1800 780 169 Email: aumedinfo@octapharma.com www.octapharma.com.au AUDE0024/00 Issue : Aug 2013