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{\footerf\pard\plain\f0\fs24\par}\pard\qc\box\brdrs\brdrw10\brsp80\brdrbtw\brdrs\brdrw10\brsp80\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs4\b\cf3\cb4\chshdng0\chcfpat0\chcbpat4\par\pard\qc\box\brdrs\brdrw10\brsp80\brdrbtw\brdrs\brdrw10\brsp80\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs28\b\cf3\cb4\chshdng0\chcfpat0\chcbpat4  HOME MEDICINES REVIEW: MEDICATION MANAGEMENT PLAN\par\pard\box\brdrs\brdrw10\brsp80\brdrbtw\brdrs\brdrw10\brsp80\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs4\cf3\cb4\chshdng0\chcfpat0\chcbpat4\par\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs16\par\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\qc\sa120\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b GENERAL PRACTITIONER DETAILS:\cell PATIENT DETAILS:\cell COMMUNITY PHARMACY:\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\plain\f1\fs24 Name: \tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs24\tab\cell Name: \tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Name:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Addressee:Name>>{\*\txfieldend}\plain\f1\fs24\tab\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Address:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Full Address>>{\*\txfieldend}\plain\f1\fs24\tab\cell Address:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:Full Address>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Address:\tab   {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Addressee:Full Address>>{\*\txfieldend}\plain\f1\fs24\par\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Provider Number: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Provider Number>>{\*\txfieldend}\plain\f1\fs24\tab\cell Medicare No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\sb119\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Phone:\tab  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Addressee:Phone>>{\*\txfieldend}\plain\f1\fs24\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Prescriber No: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Prescriber Number>>{\*\txfieldend}\plain\f1\fs24\tab\cell DVA No:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Patient Demographics:DVA Number>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Fax:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Addressee:Fax>>{\*\txfieldend}\plain\f1\fs24\tab\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Phone: \tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Phone>>{\*\txfieldend}\plain\f1\fs24\tab\cell Patient/carer contact: \tab\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Email:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Addressee:E-mail>>{\*\txfieldend}\plain\f1\fs24\tab\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Fax:\tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:Fax>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Email: \tab{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Doctor:E-mail>>{\*\txfieldend}\plain\f1\fs24\tab\cell\pard\intbl\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\plain\f1\fs24\b ACCREDITED PHARMACIST (if different)\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx5199\clvertalt\cellx10506\clvertalt\cellx15813\pard\widctlpar\intbl\pard\intbl\sb120\tx851\tqr\tx5091\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\plain\f1\fs24 Date of Pharmacist Review: \tab\cell Date of follow-up consultation:\tab\cell\pard\intbl\sb120\tx851\tqr\tx5092\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680 Name:\tab\tab\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\page\plain\f1\fs16\par\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat3\cellx15826\pard\widctlpar\intbl\pard\intbl\sb60\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b CURRENT\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 CONDITION / PROBLEM\cell\pard\intbl\sb60\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 CURRENT MANAGEMENT*\cell\pard\intbl\sb200\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 PROPOSED PLAN OF ACTION **\cell\pard\intbl\sb60\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 PERSON RESPONSIBLE\par\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 FOR ACTION ***\cell\pard\intbl\sb200\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 EXPECTED OUTCOMES\cell\pard\intbl\sb60\sa60\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 PATIENT AGREES\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\trowd\trgaph108\trleft-108\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx2444\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx5052\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6980\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx8908\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx11460\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx14295\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx15826\pard\widctlpar\intbl\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\pard\intbl\qc\sb60\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 No Action Required\cell Action (comment)\cell\pard\intbl\sb240\sa240\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\cell\cell\cell\intbl\row\pard\pard\tqc\tx7938\tx8640\tx9360\tx10080\tx10800\tx11520\tx12240\tx12960\tx13680\tx14400\tx15120\tx15840\tx16560\tx17280 * pharmacological and/or non-pharmacological\tab ** delete where applicable\tab *** nominate other health care professional if applicable\par\plain\f1\fs16\par\pard\tqr\tx4536\tx5103\tqr\tx8505\tx8931\tqr\tx11199\tx11520\tx12240\tx12960\tx13680\tx14400\tx15120\tx15840\tx16560\tx17280\plain\f1\fs24 General Practitioner: \tab\tab Patient: \tab\tab Date: \tab\tab\plain\f1\fs24\i Attach additional information if necessary\par\pard\tqr\tx4536\tx5103\tqr\tx8505\tx8931\tqr\tx11199\tx11520\tx12240\tx12960\tx13680\tx14400\tx15120\tx15840\tx16560\tx17280\par }