Blood Data Form

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BLOOD DATA FORM
This form is used to report blood results of a patient registered with the Zaponex Treatment Access System and accompanying Zaponex® (clozapine) dispensing information (if applicable) to the ZTAS.
We will use the information provided on this form in accordance with the terms of the ZTAS privacy notice which is available from the ZTAS website www.ztas.co.uk.
Patient Details
ZTAS PIN NHS Number
Name
Date of Birth  -  - 
Patient status Pre-treatmentOn-treatmentDiscontinuedNon-Rechallengeable
Monitoring Frequency WeeklyFortnightly4-weekly
Blood result details
Date of Analysis  -  - 
Reference values blood results (x 109/L)
  Green Amber Red
WBC ≥ 3.5 ≥ 3.0 / < 3.5 < 3.0
Neutrophils ≥ 2.0 ≥ 1.5 / < 2.0 < 1.5
Continuation of Zaponex treatment is not recommended when the eosinophil count rises above 3.0 x 109/L and/or the platelet count falls below 50 x 109/L; additional blood monitoring is required.
Blood result
White Blood Cell Count  .  (x 109/L)
Neutrophil Count  .  (x 109/L)
Eosinophil Count  .  (x 109/L)
Platelet Count (x 109/L)
Zaponex dispensing Information (if applicable)
Dispense date  -  - 
Number of tablets dispensed
 Zaponex 25 mg  Zaponex 100 mg Daily dosage  .  mg
Completed by
Name
ZTAS User ID GMCGPCPNIOther
Personal email
  Example: john.smith@nhs.net. Please do not use group email addresses or gmail/yahoo, etc.
Submission Date 06-Dec-2021 Signature
PSS.F01A.S07.001