HealthRX.com · Printable medication review sheet
Saxenda (liraglutide) medication review for older adults
Use this sheet before a Saxenda visit, or keep it at home, to record your current medicines, injection details, weight, heart rate, digestive symptoms and daily activity. Bring it to your prescriber or pharmacist.
Saxenda and other medicines
Write what you take now. Leave a line blank if none applies.
Saxenda start dateWrite the date you first injected Saxenda
Current Saxenda strengthCopy the strength printed on your pen label
Insulin or sulfonylureaWrite each name and how you take it, or write none
Oral medicines taken dailyList each by name, including vitamins and supplements
Recent injection sitesNote the abdomen, thigh or upper arm sites you used
Gather before the visit
- Bring your Saxenda pen and the labels for every medicine you take
- Note any missed injections and the date of the last one you took
- Write down any days you felt dizzy, weak or unusually tired
- Bring recent blood glucose readings if you use insulin or a sulfonylurea
- Note your recent resting heart rate readings if you track them at home
- Check with your pharmacist how your oral medicines are timed around injections
- Confirm whether your insurance plan requires renewal or approval for Saxenda
- Confirm any planned surgery or procedure that would need anesthesia or sedation
Weekly check-in record
Fill in one row each week and bring this page to your next visit.
| Date | Weight | Heart rate | Nausea or bowel changes | Activity done |
|---|---|---|---|---|
Questions for my prescriber or pharmacist
- Does my Saxenda strength match what is printed on my current pen label?
- Should my insulin or sulfonylurea dose be reviewed while I use Saxenda?
- How often should my heart rate be checked, and which readings should I report?
- Could my oral medicines be affected by slower emptying of the stomach?
- What should I do if I miss an injection, and when should I call?
- Will my insurance plan keep covering Saxenda while I take part in exercise classes?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.