HealthRX.com · Printable question sheet
Wegovy questions for older adults before starting or stopping
Use this sheet before a visit with your prescriber or pharmacist when Wegovy is being considered, started, changed or stopped. Fill in your medicines and health history, bring the questions and track side effects and heart rate between visits.
About me and my current medicines
Write what you can find. Bring this sheet to every visit.
Name and date of birthAs shown on your insurance card
Prescriber and pharmacyNames and phone numbers
Diabetes medicines, including insulin or sulfonylureaName and how you take each one
Heart conditions and past heart eventsInclude any stroke or heart attack
Kidney history and recent kidney test resultsDate of each test
Thyroid cancer or endocrine history in familyWrite who in the family and what condition
Other medicines and supplementsInclude doses exactly as labeled
Gather before the visit
Prepare these items so the visit covers what matters to you.
- Bring a list of every medicine, vitamin and supplement you take
- Confirm which diabetes medicines you use, including any insulin or sulfonylurea
- Note your most recent kidney test results and the date they were taken
- Bring any heart rate readings you have recorded at home
- Check with your pharmacist whether your plan covers the Wegovy injection or tablets
- Note any planned surgery, dental work or procedure that needs anesthesia or sedation
- Write down any dizziness, fainting or low blood pressure you have noticed
- Bring this sheet and any notes from earlier visits
Questions to ask your prescriber
- Is Wegovy an option for me given my age and my heart and kidney history?
- Will my insulin or sulfonylurea dose need to change when Wegovy is started?
- How often should my heart rate be checked while I am using Wegovy?
- Which signs of fluid loss or dehydration should I report to you right away?
- How should I plan for a procedure that needs anesthesia while I take Wegovy?
- What would you watch for if I feel dizzy or my blood pressure drops?
- What is the plan if nausea, vomiting or unusual skin sensations develop?
- What would stopping Wegovy mean for my weight and heart health over time?
Side effects and heart rate tracker
Record each day or week. Share the completed table at your next visit.
| Date | Dose step | Heart rate | Side effects | Dizziness or fainting |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.