Carta De Peticion

Herceptin Guided Questionnaire
Infusion Related Reactions

|AER: | | |Local Case ID: ||
|Site No: | | |Patient Date of Birth | |
|| | |(dd-MMM-yyyy): | |
|Patient ID/Initials: | | || |
|Patient Gender: |( M ( F | | ||

Infusion Related Reactions (IRRs) have been observed in some patients treated with Herceptin.

By filling in this questionnaire, you will help us to more fullyunderstand the risk factors for this condition.

|Reporter Information ||Name of reporter completing this form (if other than addressee, provide contact information below): |
|Health Care Provider? ( Yes ( No-Specify:|
|Phone number: |Fax number:|
|Email address:|

|Description of the event |
|( Cutaneous symptoms...