Australia’s own SClg

My EvogaM® Journal

10788 Evogam NZ Patient Diary FA4

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Australia’s own SClg

Welcome to your journey with EvogaM

EvogaM is a liquid immunoglobulin (Ig) therapy designed for subcutaneous use. You have been prescribed EvogaM because you have either primary immunodeficiency disease (PID) or symptoms of hypogammaglobulinaemia due to another underlying condition. With EvogaM, you have the freedom and flexibility to infuse therapy at a time and place that is most convenient for you.

This diary is designed to help you get the most out of your therapy; and keep on top of your treatment schedule and medical appointments.

The diary is divided into two sections:

1. Contact details and appointments

2. Infusion records

Contents My personal details 1

My healthcare team’s contact details 2

My medical appointments 4

My infusion records 8

D D

1

Australia’s own SClg

Contact Details

My personal details

Name: ________________________________________________________

address: _______________________________________________________

__________________________________________ Postcode: ___________

Phone: (Home) ___________________ (Work) _______________________

(Mobile) _________________________________________________

Email: _________________________________________________________

Health insurance policy no.: _______________________________________

allergies: _______________________________________________________

_______________________________________________________________

_______________________________________________________________

In case of emergency please notify

Name: ________________________________________________________

address: _______________________________________________________

__________________________________________ Postcode: ___________

Phone: (Home) ___________________ (Work) _______________________

(Mobile) _________________________________________________

2

My healthcare team’s contact details

Specialist name: _________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

Specialist name: _________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

Specialist name: _________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

Nurse name: ____________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

3

Australia’s own SClg

Nurse name: ____________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

Nurse name: ____________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

Nurse name: ____________________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

general practitioner name: ________________________________________

Hospital/clinic name: _______________________________________ ______

_____________________________________ Phone: ___________________

4

My medical appointments

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

5

Australia’s own SClg

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

Name:

Date: ______________________Time:

Hospital/clinic name:

6

Infusion Records

My infusion records

Keep track of your therapy each week

It takes commitment and some organisation to stay on track with your infusions. To get the most out of your therapy, it is important to keep a record of your treatment and share it with your doctor or nurse. This journal can make it easier for you to record important information, such as:

• Dates and times of your infusions

• Dosage

• Lot number and expiration date of the EvogaM used

• Side effects you may experience

• Medications you take and illnesses you experience

once you are infusing on your own, bring your journal to each follow-up visit with your doctor or nurse.

Fill in your infusion record every time you infuse EvogaM.

7

Australia’s own SClg

8

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

9

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

10

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

11

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

12

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

13

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

14

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

15

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

16

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

17

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

18

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

19

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

20

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

21

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

22

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

23

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

24

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

25

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

26

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

27

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

28

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

29

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

30

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

31

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

32

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

33

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

34

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

35

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

36

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

37

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

38

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

39

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

40

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

41

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

42

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

43

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

44

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

45

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

46

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

47

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

48

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

49

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

50

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

51

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

52

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

53

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

54

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

55

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

56

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

57

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

58

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

59

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

60

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

61

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

62

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

63

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

64

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

65

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

66

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

67

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

68

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

69

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

70

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

71

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

72

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

73

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

74

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

75

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

76

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

77

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

78

Day Month Year

affix label here

affix label here

affix label here

affix label here

My infusion record

Notes on my EVOGAM therapy

Week: ________________________________Dosage: __________________

Infusion no. for this week: _______ Date of infusion: _________________

Duration of infusion: ___________________ (hours)

Peel “lot number and expiration date” labels from EVOGAM vials used and affix in spaces below.

Number of sites and areas infused this week (please mark with an X)

79

Australia’s own SClg

My treatment diary

Use this section to record any symptoms, side effects, illness, infection or anything else you wish to discuss with your healthcare professional at your next visit.

MedicinesUse this section to record any medications you took over the last week. (Please include non-prescription as well as prescription medications):

Name of medicine Dose and Frequency Start date Stop date

Australia’s own SClg

CSL Behring (Australia) Pty Ltd 189–209 Camp Road, Broadmeadows,

Victoria, Australia 3047 ABN: 48 160 734 761

10788. CSL Behring. DC-5500. Date of preparation: June 2013

If you have any questions or concerns after reading this booklet,

please ask your doctor or nurse.