CLOZAPINE GP SHARED CARE REVIEW FORM
Clozapine Clinic, Psychosis, Woolloongabba Community Health Centre 
Email: MSAMHS_Clozapine@health.qld.gov.au  Fax: 3176 1279
(BP, V3.0, September 2020) 
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RE Patient Name:  <PtName>  		
DOB: <PtDoB>
GP Name: <DrName>		
Practice: <Practice>
Examination Date:    <TodaysDate>

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Consider longer appointments for 6 monthly & annual reviews

FBE PERFORMED EVERY 28 DAYS & EACH REVIEW   
This months FBE result is in the: <This month's FBE is in the>

PHYSICAL ASSESSMENT EVERY 28 DAYS & EACH REVIEW     
Physical Assessment Performed: <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. Report any medication changes

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 Psychosis ACU, Woolloongabba Community Health Centre. After hours enquiries can be directed to MH CALL 1300 64 22 55
Current dose of Clozapine:  <Current dose of Clozapine>
Pathology request 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?>
Smoking history: <SmkHx> 
Smoking quitting stage:  <SmkStatus>

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6 MONTHLY METABOLIC SCREENING 
Please report any abnormalities to Psychosis ACU, WCHC and treat as appropriate
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>
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6 MONTHLY MEDICATION REVIEW           
Current Medications: <CurrentRx>
Annual Home Medicine Review: <Annual Home Medicine Review>

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ANNUAL CARDIAC SCREENING
(Please report any abnormalities to Psychosis ACU, WCHC and treat as appropriate)
Date of ECG: <Date of Annual ECG> 		Result: <Result of Annual ECG>		
Date of Echocardiogram: <Date of Annual Echocardiogram> 		Result: <Result of Annual Echocardiogram>

ADDITIONAL COMMENTS	 
<Additional Comments>

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COMPLETION INSTRUCTIONS: <COMPLETION INSTRUCTIONS>
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