WA Health, Government of Western Australia
|The Health (Notification of Stimulant Induced Psychosis) Regulations 2010 requires a psychiatrist who makes a diagnosis of stimulant induced psychosis in |
|respect of a patient to notify the Department of Health within 72 hours of making a diagnosis. |
| |
|Patient details |
|First name: | |Surname: | |DOB: | |
|Address: | |Suburb: | |Postcode: | |
|Aliases: | |Gender: | Male | Female | Unspecified |
|Is this person of Aboriginal or Torres Strait Islander origin: |
| No | Yes, Aboriginal | Yes, Torres Strait Islander | Both Aboriginal & Torres Strait Islander |
| |
|Diagnosis |
|Diagnosis (ICD-10 code or description): | |
|Stimulant/s precipitating diagnosis: | |
|Access to stimulant/s: | licit illict |
|Has a urine drug screen been performed: | Yes, please attach copy | No |
| |
|Notifying psychiatrist |
|First name: | |Surname: | |
|Name of facility at which diagnosis was made: | |
|Address: | |Suburb: | |Postcode: | |
|Telephone | |Fax: | |Email: | |
| |
|Prescriber contact |
| |
|If the patient is being treated with prescribed stimulant medicines, has the stimulant prescriber been contacted? |
| Yes | No |
| |
|Declaration |
|I hereby notify the Chief Executive Officer of the Department of Health, as required by the Health (Notification of Stimulant Induced Psychosis) Regulations |
|2010, that the abovementioned patient has experienced a psychotic episode, as per the above diagnosis, induced by or associated with the use of the stimulants |
|listed above. |
|Signature: | |Date: | |
| |
|Office Use Only |
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Notification
Stimulant Induced Psychosis
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