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Notification of treatment with stimulant medication 1. Patient details Forenames: Surname: Address: Suburb: DOB: / / Medicare no: Postcode: Gender: M F Weight (kg) (children only): 2. Notification type Notification Renotification Dose Drug Drug form Co-prescriber Termination No further Rx Patient moved Side effects Diversion Substance abuse Prescriber moved/retired Outside Stimulant Prescribing Code Bipolar Patient details Other: Age <4 years Age 15-17 years High dose Psychosis Substance abuse (last 5 years) Non-standard condition Note: Prior written authority from the CEO of Health is required to prescribe outside the criteria set out in the Code. A comprehensive clinical report and information from the relevant application checklist is to accompany all applications. 3. Primary condition being treated ADHD If ADHD is primary condition: Which diagnostic criteria were used? DSM-5 ICD-10 Brain damage Patient on other psychotropic medicines? Yes No Narcolepsy Please specify: Antidepressants Anxiolytics Antipsychotics Mood stabilisers Depression Non-standard, please specify: Other, specify: 4. Stimulants to be prescribed and total daily dose Dexamphetamine: mg/day Lisdexamphetamine: mg/day Methylphenidate: mg/day Dexamphetamine compounded: mg/day Methylphenidate long acting: mg/day 5. Authorised Stimulant Prescriber Forenames: Surname: SPN: Is the patient being treated at a Registered Public Clinic? Yes No If yes, please specify: Practice: Address: Suburb: Postcode: 6. Co-Prescriber Nominated co-prescriber only Forenames: All practitioners at the same practice as nominated co-prescriber Surname: Practice: SPN holder is required to provide a copy of the Notification to the nominated co-prescriber 7. Acknowledgement Medical practitioner I confirm that I have made the patient/parent/guardian aware that the information included on this form will be forwarded to the Department of Health (WA) to meet legislative requirements and that de-identified data may be used for the purpose of authorised research. I also hereby notify the Chief Executive Officer (CEO) of Health that the above patient will be treated in accordance with the Stimulant Prescribing Code and in accordance with a written authorisation from the CEO if required. Signature: __________________________________ Date: / / Forms available from: www.health.wa.gov.au/stimulants Pharmaceutical Services Branch PO Box 8172, Perth Business Centre WA 6849 Fax 9222 2463 Phone 9222 6883 0058 06 15