HealthRX.com · Printable medication review sheet
Saxenda to generic liraglutide switch review sheet
Use this sheet when moving from Saxenda to a generic liraglutide pen, or when a pharmacy changes the product. Fill it in by hand and bring it to your prescriber or pharmacist before the first switched injection.
Product and label details
Copy these from the pen box and the pharmacy label.
Product on the current penSaxenda or generic name as printed
Generic manufacturer named on boxFor example Teva, Biocon or Cipla
Brand the generic referencesSaxenda or Victoza, if stated in the insert
Labeled use shown on paperwork
Date of last Saxenda injection
Pharmacy name and phone
Prescriber name
Gather and confirm before the visit
- Bring the current pen box and the new pen box
- Bring the patient information leaflet from each product
- Note the date and time of your most recent injection
- Confirm with the pharmacist which brand the new generic references
- Check the paperwork for the labeled use of the new product
- List every other medicine and supplement you take
- Write down any gap in doses since the last injection
Dose and gap tracker
Write one row for each day you inject. Mark any day that followed a missed period.
| Date | Product used | Dose or step | Days since last dose | Side effects noted |
|---|---|---|---|---|
Questions for your prescriber or pharmacist
- Does the generic I was given reference Saxenda or Victoza?
- Which labeled use applies to the product I will inject?
- Should I restart the dose schedule after my gap in doses?
- Does the label for this product set a checkpoint for weight change?
- What is the maximum labeled dose for this product?
- Which symptoms should prompt me to stop and call for help?
- Can I use this product alongside my other medicines?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.