Author: Jenaya Price

Clozapine GP Shared Care Review Form
Clozapine Clinic, Psychosis, Woolloongabba Community Health Centre
Email: MSAMHS_Clozapine@health.qld.gov.au   Fax: 3176 1279
(ZM V3.0 September 2020)

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PATIENT DETAILS 
RE: Patient Demographics.First Name Patient Demographics.Surname		
DOB: Patient Demographics.DOB	
GP Name: Treating Doctor.Full Details
Practice: Practice.Name
Examination Date: Miscellaneous.Date

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FBE PERFORMED EVERY 28 DAYS & EACH REVIEW
Consider longer appointments for 6 monthly and annual reviews

This month's FBE is in the: FBE Range

PHYSICAL ASSESSMENT EVERY 28 DAYS & EACH REVIEW: Physical assessment
General health check inc. blood pressure and weight: Health check
Examine mouth & throat for signs of infection: Examine mouth 
Check temperature, heart sounds & pulse rate: Check temperature
Assess for any adverse side effects from clozapine: Assess side effects

Please note any abnormalities in additional comments section below & treat as appropriate. Report any medication changes

BRIEF MENTAL STATE ASSESSMENT EVERY 28 DAYS & REVIEW

Mental State Assessment: Mental State 

Please report any notable deterioration in mental state to Psychosis ACU, Woollooongabba Community Health Centre. After hours enquiries can be directed to MH CALL 1300 64 22 55

Current dose of clozapine: Dose of clozapine
Pathology request completed for test due in 28 days?: Pathology
Next appointment due in 28 days. Appointment made?: Appoinment made
Currently smoking: Clinical Details.Smoking
Recently stopped smoking: Smoking

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6 MONTHLY METABOLIC SCREENING
Please report any abnormalities to Psychosis ACU, Woolloongabba Community Health Centre and treat as appropriate

Height:: Current Measurements.Physical - Height    Weight: Current Measurements.Physical - Weight
Waist: Current Measurements.Physical - Waist Measurement   BP: Current Measurements.Physical - Diastolic BP (Sitting)   Heart rate: Current Measurements.Physical - Pulse

Fasting blood glucose: Blood glucose
Lipids: Lipids
LFT: LFT
U&E: U&E
Referral to dietician: Referral

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6 MONTHLY MEDICATION REVIEW

Current medications: Clinical Details.Medication List
Annual Home Medicine Review: Medication review

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ANNUAL CARDIAC SCREENING
Please report any abnormalities to Psychosis, ACU, Woolloongabba Community Health Centre and treat as appropriate. Please attach a copy of the results

ECG: ECG  Result: ECG Result
Echocardiogram: Echocardiogram date  Result: Result

Additional comments: Comments

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Completion instructions: Completion

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RE: Patient Demographics.Full Name Patient Demographics.DOB
Clozapine GP Shared Care Review Form, ZM V3.0, September 2020