Download Notification of treatment using stimulant medication (Word 40KB)

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