HealthRX.com · Printable medication review sheet
Liraglutide handoff record for Saxenda and Victoza
Use this sheet when an older adult on liraglutide moves from geriatric care to adult care. Write down the exact product, dose, last dose and any linked medicine changes so the receiving team can confirm them.
Product identity and current dose
Write exactly what the pharmacy label says. The same drug name covers two products.
Product nameSaxenda or Victoza, as printed on the pharmacy label
Generic or brand name on labelNote which product a generic label says it references
Current dose in mg and how it is givenDose and injection site as written on the latest order
Date of the most recent doseDate only, from your own record or the pharmacy
Start date of this productThe date the first dose was given
Prescriber and clinicName and phone number of the current prescriber
Gather before the handoff visit
Bring copies, not originals, unless the clinic asks for them.
- Bring the pharmacy label or box for each liraglutide product in use.
- Write down every sulfonylurea or insulin dose and note any reduction made when liraglutide started.
- Bring the most recent kidney test result and note any recent vomiting or diarrhea.
- List any planned surgery or procedure that involves sedation or general anesthesia.
- Check with the pharmacy whether a generic liraglutide is being dispensed and which product it references.
- Bring any older transition summary and mark any line about suicidal thoughts for the team to review.
- Note any missed or interrupted doses since the last visit, including time spent in hospital.
Dose and interruption record
Record each dose or missed day. Write the reason for any gap.
| Date | Dose taken | Missed days | Reason or symptom |
|---|---|---|---|
Questions to ask the prescriber or pharmacist
- Which liraglutide product should I be on for my condition, and what is its maximum dose?
- After a gap of more than a few days, where should my dose restart and who sets the next steps?
- If I take a sulfonylurea or insulin, should that dose change now that liraglutide is in use?
- Does my kidney test need repeating after vomiting or diarrhea, and when should it be done?
- Who should be told about my planned surgery, and should liraglutide be addressed before it?
- Does my Saxenda start date mean a weight check is due, and who will do it?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.