PATIENT / CARER QUESTIONNAIRE Name of organisation (only applicable if you are submitting information on behalf of a patient organisation or support group): Medicine and indication under consideration: Adalimumab (Humira®) for the treatment of active moderate to severe hidradenitis suppurativa (acne inversa) in adolescents from 12 years of age with an inadequate response to conventional systemic HS therapy Date by which questionnaire should be received: 17th April 2017 We would like to understand the patient / carer experience and any information you are able to provide, either positive or negative, would be very helpful. We contact clinical experts to give the clinical facts and views. Please complete this questionnaire and email it to the All Wales Therapeutics and Toxicology Centre () at the email address below. Alternatively you may complete the questionnaire by hand and return it to the postal address below. Should you have any queries or if for whatever reason you find it difficult to complete this questionnaire then please contact (see contact details below) and we will endeavour to help. It is not possible for questionnaires to be presented in person at the appraisal meetings the patient – advocate (i.e. the lay member) will undertake this role. The information contained in this questionnaire will not be posted on the , but will be circulated to members with other documents prior to the appraisal meetings. Section 1: General information and medicine-specific details: To be completed by patients, carers and family members, or patient organisations on their behalves. Experience of the condition and associated treatments (information may be equally relevant to any future submissions that you might make). Information specific to the medicine under consideration. Section 2: Patient organisation details: Only to be completed if you are submitting information on behalf of a patient organisation or support group. These details may not change and can be used for any other questionnaires that the patient organisation wishes to complete (in relation to other medicines/appraisals). Section 1: General information & medicine-specific details Section 1 should be completed by patients, carers and family members, or patient organisations on their behalves.
PATIENT / CARER QUESTIONNAIRE Name of organisation (only applicable if you are submitting information on behalf of a patient organisation or support group): Medicine and indication under consideration: Adalimumab (Humira®) for the treatment of active moderate to severe hidradenitis suppurativa (acne inversa) in adolescents from 12 years of age with an inadequate response to conventional systemic HS therapy Date by which questionnaire should be received: 17th April 2017 We would like to understand the patient / carer experience and any information you are able to provide, either positive or negative, would be very helpful. We contact clinical experts to give the clinical facts and views. Please complete this questionnaire and email it to the All Wales Therapeutics and Toxicology Centre () at the email address below. Alternatively you may complete the questionnaire by hand and return it to the postal address below. Should you have any queries or if for whatever reason you find it difficult to complete this questionnaire then please contact (see contact details below) and we will endeavour to help. It is not possible for questionnaires to be presented in person at the appraisal meetings – the patient advocate (i.e. the lay member) will undertake this role. The information contained in this questionnaire will not be posted on the , but will be circulated to members with other documents prior to the appraisal meetings. Section 1: General information and medicine-specific details: To be completed by patients, carers and family members, or patient organisations on their behalves. Experience of the condition and associated treatments (information may be equally relevant to any future submissions that you might make). Information specific to the medicine under consideration. Section 2: Patient organisation details: Only to be completed if you are submitting information on behalf of a patient organisation or support group. These details may not change and can be used for any other questionnaires that the patient organisation wishes to complete (in relation to other medicines/appraisals). Section 1: General information & medicine-specific details Section 1 should be completed by patients, carers and family members, or patient organisations on their behalves.
Patient_Organisation_Questionnaire.docx