DEPOT GP SHARED CARE (LAI) REVIEW FEEDBACK FORM
Fax: 07 3078 2120
(MD, V1, July 2024) 
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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>>
Ethnicity: <<Patient Demographics:Ethnicity>>
Is an interpreter required: <<Is an interpreter required>>

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Consider using 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 28 days and review>>  
Please report any notable deterioration in mental state to <<Name and phone no of relevant MSAMHS team>>. After hours enquiries can be directed to MH CALL 1300 64 22 55

DEPOT ADMINISTRATION
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 no of relevant MSAMHS team>> and treat as appropriate
Observations: <<Clinical Details:Measurements (Selected)>>     
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 <<Name and No of relevant MSAMHS team>> 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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