Clozapine Blood Work Monitoring Log Form
Clozapine Blood Work Monitoring Log
Patient Identifier or Record Code
*
Log Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prescribing Clinician
*
Blood Test Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Test Type
*
Please Select
Routine Monitoring
Initial Baseline
Urgent/Repeat
Other
Lab Name
*
White Blood Cell Count (WBC, x10^9/L)
*
Absolute Neutrophil Count (ANC, x10^9/L)
*
Result/Status
*
Please Select
Within Normal Range
Below Threshold
Requires Follow-Up
Other
Follow-Up Notes or Next Scheduled Monitoring Date
Submit Log
Should be Empty: