Clozapine Myocarditis Monitoring Checklist
Complete this checklist to monitor for signs and symptoms of myocarditis in patients taking clozapine.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Initials
*
Age
*
Temperature (°C)
*
Heart Rate (beats per minute)
*
Blood Pressure (mmHg)
*
Recent onset of fever?
*
Yes
No
Unknown
Chest pain or discomfort?
*
Yes
No
Unknown
Shortness of breath or difficulty breathing?
*
Yes
No
Unknown
Unusual fatigue or malaise?
*
Yes
No
Unknown
Submit Checklist
Should be Empty: