HealthRX.com · Printable medication review sheet
Trulicity (dulaglutide) care transition record for older adults
Use this sheet when an older adult's Trulicity care moves to a new prescriber, pharmacy or care setting. Fill it in by hand, bring it to the visit, and keep a weekly injection and symptom record at home.
Transition details
Copy these from the pen label, pharmacy record and current medicine list.
Receiving prescriberName and clinic phone
Pharmacy namePharmacy and phone
Trulicity dose strength on labelWrite the strength exactly as printed
Weekly injection dayDay of the week the injection is usually given
Date of last injection
Insulin or sulfonylurea on listWrite each name and its current dose strength
Planned surgery, procedure or sedationDate and provider
Gather before the visit
- Bring the Trulicity pen or box and the patient information leaflet
- Bring a full list of all medicines, supplements and over-the-counter products
- Note any vomiting, diarrhea or inability to keep fluids down since the last visit
- Check the injection record below and bring it to the visit
- Confirm the date and result of the most recent kidney blood test
- Confirm which pharmacy will fill future Trulicity prescriptions
- List any past thyroid, pancreas or gallbladder problems reported to any provider
- Write down any eye problems the patient has had, including diabetic eye changes
Questions to ask at the visit
- Does the Trulicity dose stay the same for this patient's age, or does the prescriber plan changes?
- Should the insulin or sulfonylurea dose be reviewed now that Trulicity is being continued?
- What low blood sugar signs should the patient and caregiver watch for, and what should they record?
- Should kidney function be checked during any period of vomiting or diarrhea?
- What is the missed-dose plan for the weekly day used by this patient?
- Can the weekly injection day be moved, and what is the rule for doing so?
- How should planned surgery or deep sedation be handled while on Trulicity?
- Who should the patient call first if symptoms stop them from eating or drinking?
Weekly injection and symptom record
Record one line each week. Bring this log to every visit.
| Injection date | Injection site | Day moved or missed | Stomach symptoms | Low sugar reading |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.