CLOZAPINE GP SHARED CARE REVIEW FORM
(V2.1 MD, Reviewed: Nov 2018) 
Patient Name, RE:  <<Patient Demographics:Full Name>>  		DOB: <<Patient Demographics:DOB>>
UR: <<(If relevant) UR >>
GP Name:   <<Doctor:Name>>		Practice: <<Practice:Name>>
Examination Date:    <<Miscellaneous:Date>>
Required Clozapine Facility: <<Required LBMHS Clozapine Facility>>

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(Consider using the outstanding Action/Recall feature of your clinical software to plan reviews. 
Consider longer appointments for 6 monthly & annual reviews.)
FBE PERFORMED EVERY 28 DAYS & EACH REVIEW
This months FBE result is in the: <<This months FBE is in the>>

PHYSICAL ASSESSMENT EVERY 28 DAYS & EACH REVIEW     <<Physical Assessment Performed>>
General Health Check inc. Blood Pressure & Weight:  <<General Health Check >>
Examine mouth & throat for signs of infection: <<Mouth and Throat Examination>>
Check temperature, heart sounds & pulse rate:  <<Temperature, Heart Sounds, Pulse Rate>>
Assess for any adverse side effect from Clozapine: <<Adverse Side Effects from Clozapine>>
(Please note any abnormalities in the additional comments section below and treat as appropriate.  
Any medication changes must be reported to LBMHS)
BRIEF MENTAL STATE ASSESSMENT EVERY 28 DAYS & EACH REVIEW 
Brief Mental State Assessment Results: <<Brief Mental State Assessment every 28 days>>  
(Please report any notable deterioration in mental state to LBMHS and if appropriate consider re-referral back to LBMHS)
Current dose of Clozapine: <<Current dose of Clozapine>>
Smoking history: <<Clinical Details:Smoking>>
Smoking quitting stage: <<Clinical Details:Smoking Quitting Stage>>
Pathology request form completed for test due in 28 days: <<Pathology request completed for 28 days time?>>
Next appointment made for 28 days time: <<Appointment made for 28 days time?>>

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6 MONTHLY METABOLIC SCREENING 
(Please report any abnormalities to LBMHS and treat as appropriate.  Consider referral to dietitian)
Height - complete 6 monthly:  <<Height - complete 6 monthly>>
Weight - complete 6 monthly :  <<Weight - complete 6 monthly>>    
Waist:  <<Waist - complete 6 monthly>>   
BMI:  <<BMI - complete 6 monthly>>
Fasting Blood Glucose:  <<Fasting Blood Glucose - complete 6 monthly>> 
Lipids:   <<Lipids - complete 6 monthly>>  
LFT:  <<LFT - complete 6 monthly>>   
U and E:  <<U and E - complete 6 monthly>>
Referral to Dietitian: <<Referral to Dietitian>>

6 MONTHLY MEDICATION REVIEW
Current Medications: <<Clinical Details:Medication List>>

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ANNUAL CLOZAPINE CARDIAC SCREENING 
(Please report any abnormalities to LBMHS and treat as appropriate)
Date of ECG: <<Date of annual ECG>>  			Result: <<Result of Annual ECG>>
Date of Echocadiogram: <<Date of annual Echocardiogram>> 		Result: <<Result of Annual Echocardiogram>>

ANNUAL HOME MEDICINE REVIEW
<<Annual home medicine review>>

ADDITIONAL COMMENTS	
<<Additional Comments>>

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COMPLETION INSTRUCTIONS: <<COMPLETION INSTRUCTIONS>>

______________________________________________________________________________________________________                             RE: <<Patient Demographics:Full Name>>           D.O.B:<<Patient Demographics:DOB>>
Logan - Beaudesert Mental Health Services (LBMHS) Clozapine GP Shared Care Review Form                                 MDV2.1 Nov 2018

______________________________________________________________________________________________________                                                RE: <<Patient Demographics:Full Name>>           D.O.B:<<Patient Demographics:DOB>>
Logan - Beaudesert Mental Health Services (LBMHS) Clozapine GP Shared Care Review Form                                 MD V2.1 Nov 2018