DEPOT GP SHARED CARE (LAI) REVIEW FEEDBACK FORM
Fax: 07 3078 2120
(BP, V1, July 2024) 
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RE Patient Name:  <PtName>  		
DOB: <PtDoB>
GP Name: <DrName>		
Practice: <Practice>
Examination Date: <TodaysDate>   
Ethnicity: <PtEthnicity>
Is an interpreter required: <Is an interpreter required>
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Consider longer appointments for 6 monthly & annual reviews
PHYSICAL ASSESSMENT     
Physical Assessment Performed: <Physical Assessment Performed>
General Health Check inc. Blood Pressure & Weight:  <General Health Check >
Assess for any adverse side effect from LAI medication: <Adverse Side Effects from LAI medication>
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 and each review>  
Please report any notable deterioration in mental state to <Name and phone number of relevant MSAMHS team>. 
After hours enquiries can be directed to MH CALL 1300 64 22 55
DEPOT ADMINSTRATION
Depot administered  <Depot administered>
Name of medication administered: <Name of medication administered>
Dose: <Dose in milligrams>
Given by: <Dose given by> 
Site administered: <Site administered> 
Appointment made: <Appointment made?>
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6 MONTHLY METABOLIC SCREENING 
Please report any abnormalities to <Name and number of relevant MSAMHS team> and treat as appropriate
Height : <Observations>  
Fasting Blood Glucose:  <Fasting Blood Glucose> 
Lipids: <Lipids>  
LFT: <LFT>   
U and E: <U and E>
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 <Name and number of relevant MSAMHS team>and treat as appropriate)
Date of ECG: <Date of ECG> 		Result: <Result of ECG>		
Date of Echocardiogram: <Date of Echocardiogram> 		Result: <Result of Echocardiogram>

ADDITIONAL COMMENTS	 
<Additional Comments>
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COMPLETION INSTRUCTIONS: <Completion instructions>
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