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Österreich
IDELVION Case Report

Bitte beachten Sie, dass Sie vor der Befüllung des untenstehenden Formulars einen unterzeichneten Vertrag mit CSL Behring benötigen.

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Allgemeine Informationen zu den Case Reports: Flyer Case Reports Idelvion®

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Physician completing the form
*Date completed
*Completed by
*Centre
*Country
Contact details
*Phone:
*E-mail Address:
Demographics
Gender
Date of birth
Haemophilia history
Age at diagnosis
*Haemophilia B Severity
How was the patient diagnosed?
Treatment history (prior to IDELVION)
Treatment Type
Product(s) Used
Dosing Regimen(s)
FIX Activity (IU/dL)
Clinical Phenotype (prior to IDELVION)
Number of Bleeds
Number of Breakthrough Bleeds (on Prophylaxis)
Treatment of Breakthrough Bleeds (On Prophylaxis)
Location of Bleeds
Joint Involvement
Lifestyle (prior to IDELVION)
Physical Activity
Limitations/Difficulties
Other Comments
IDELVION treatment
Reason for Switching to IDELVION
Date of Switching
Initial Dose Regiment of IDELVION
Basis for Decision
Subsequent Changes to IDELVION Dose Regimen, if applicable
FIX Activity (IU/dL)
Clinical Phenotype with IDELVION
Number of Bleeds
Number of Breakthrough Bleeds
Location of Bleeds
Joint Involvement
Lifestyle Since Receiving IDELVION
Physical Activity
Impact of IDELVION
Patient Satisfaction
Other Comments
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