CLOZAPINE GP SHARED CARE REVIEW FORM
 Clozapine Clinic, Psychosis, Woolloongabba Community Health Centre
Email: MSAMHS_Clozapine@health.gov.au    Fax: 3176 1279
(MD, V3.0, Reviewed September 2020) 
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Patient Name, RE:  <<Patient Demographics:Full Name>>  		
DOB: <<Patient Demographics:DOB>>
GP Name:   <<Doctor:Name>>		
Practice: <<Practice:Name>>
Examination Date:    <<Miscellaneous:Date>>

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Consider using 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. 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 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?>>
Smoking history: <<Clinical Details:Smoking>>
Smoking quitting stage: <<Clinical Details:Smoking Quitting Stage>>

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6 MONTHLY METABOLIC SCREENING 
Please report any abnormalities to Psychosis ACU, Woolloongabba Community Health Centre 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: <<Clinical Details:Medication List>>
Annual Home Medicine Review: <<Annual Home Medicine Review>>

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