HealthRX.com · Printable question sheet
Enclomiphene safety questions for your prescriber
Use this sheet before a visit about enclomiphene citrate, a medicine not approved by the FDA or EMA. Fill in your history, bring your records, ask the questions and track any side effects between visits.
My history and current results
Write what applies to you. Leave blank anything you do not know.
Reason I am considering enclomipheneYour own words
Most recent testosterone result and dateCopy from your lab report
Most recent sperm count result and dateCopy from your lab report
Blood clot or heart history in me or familyWho, what and when
Liver, thyroid or adrenal history
Eye or vision problems I have had
Past use of clomiphene or ClomidDates and what happened
Before the visit
Gather these so the visit can cover the evidence gaps.
- Bring a list of every medicine, supplement and hormone product you take
- Bring recent blood results for testosterone, LH, FSH and estradiol
- Confirm whether the product is FDA approved or made by a compounder
- Note the pharmacy, source and label details of any enclomiphene supplied
- Check with your pharmacist whether the product is a compounded bulk substance
- Bring a note if you compete in sport, so the prohibited list can be checked
- Write down any eye changes such as blurring, spots or flashes before the visit
Questions to ask
- Is enclomiphene approved for my condition, and what is the evidence behind my plan?
- Since long-term safety data are lacking, how will you monitor me over time?
- How will you check for clot or heart changes during treatment?
- How often will my sperm count and hormone levels be checked?
- Will my eyes be checked, and what should I report to you right away?
- What happens to my testosterone if I stop, and how soon would I see it?
- Does my compounding pharmacy meet the rules, and where is the product sourced?
- Would my symptoms of low testosterone be tracked, since trials did not measure them?
Side effects I notice
Track between visits and bring this page with you.
| Date | Symptom | Severity | Still happening? |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.