Attachment Samples of Case Report Forms in NDA

PATIEKTS lDENTlFtCATlON AGE:64 caucasim x DATE OF BIRTH: 5-8-l 1 Black - y! ,.,, .~ DURATION ‘.LOCAtlZATION: Left low& &lid Years12 SUMMARY OF CASE HISTORY: Lesion which siowiy incxwsed in size. DESCRIPTION: MorwIs- --_ __-.- ---- -r-----.------ Weeks __ DayS- Triangular shaped lesion with numerous waxy pap&s, dotted over the surface of ihe lesion. scars and crusted ulcerations EXTENSION 40 mm. x 13 mm. PREVIOUS TREATMENTS NOM Dermex . ..._I ,.._/...-. - - .- ; -.."... ._, -,... .. . rmaceuticais, LLC <. .HUMAN’.’ .. CLINICAL REPO’RT NAME OF PATXEW ADREsS! I Date of Birth Male Female 1 Attending Physician Name Address .. e DIAGNOSIS . , : f-.-JA# or Biopsy _.,. . _ -- Visual LOCATION OF L&ION Treatment 1,2,&J applications Follow up examination Side Effects: CONCLUSION 14 / p~l{1IIll1IIlIIIl~IIIII~II~~ it*. .&._;--L-.- ._.. i ..?_ c..~ .,,.. <_..a:-.. .,.. L.?. . ;; &_.._.,_.;..... .-. :,,.y.,, +. :.= : . Cirm& ., -- -, .- ._.. *_._.:. . -... I..?.. _____ li ;* .T. x I._. ..&“&.&.+sd ‘*- --. .----m.LI)-lll. T,d”.L?..-.-.d. .-.. i._^. ,‘. Pharmaceuticals, LLC . L i.- ., i!@ 1 NAME OF PA’$‘IEN$ 1 t I Date of Birth Male v HUMAN ‘-CLINICAL WPORT 1 FemaIe Attending Physician Name Address Phone # 2 , I Q -_ Visual. c or Biopsy //y/d , -- * LOCATION OF LESION SIZE OF LESION Treatment 1,2, or 3 appkations Follow up-examination b J. Side Effects: CONCLUSION v .. . Dermex LLC Pharmaceu~icd,y, .- . .. 1 1 -, HUMAN : CLINICAL REP&T NAME OF PATIEW: -ADDRESS . ! 1 t Date of Sikh Male Female _., .. 4 Product # Attending Physician pl&7&$---: Name V e Address a. I- .. Phone# DIAGNOSIS I. . R * Visual or Biopsy Y /7 -- LOCATION OF LESIQN- WW’ y’ SIZE OF LESION. Z ’ Treatment 1,2, or3 applications / FoIlow up examination Side Effects: nfixrnr t~0~fi-v