HealthRX.com · Printable question sheet
Longevity medicines questions for your prescriber
Use this sheet before or at a visit about metformin, semaglutide or tirzepatide, rapamycin, testosterone or estrogen, NMN or NR, acarbose or low-dose naltrexone. Fill it in by hand and bring it to your prescriber or pharmacist, or keep it at home to track.
Medicines and supplements I am asking about
Write one line for each medicine or supplement you take or are considering.
Medicine or supplement nameFor example metformin, semaglutide, rapamycin, NMN
Strength and how often I take itCopy exactly from the label or prescription
Who prescribed or recommended itName of prescriber, clinic or shop
Reason I was given for itIn the prescriber's own words if possible
Any reactions or side effects I have noticed
Bring or confirm before the visit
Bring copies, not originals, of lab results.
- Bring a full list of current prescriptions, including any NMN, NR or other supplements.
- Bring any coronary artery calcium score or DEXA body scan report you have.
- Note your family history of thyroid cancer, breast cancer, prostate cancer or blood clots.
- Confirm which pharmacy fills each medicine and ask for its phone number.
- Check with your insurer whether metformin, rapamycin or NMN is covered for longevity use.
- Write down any medicine you stopped and the date you stopped it.
Questions to ask my prescriber
- Is my reason for this medicine a documented deficiency, a risk factor or a general longevity goal?
- Which of my labs would make you change, pause or stop this medicine?
- Is this medicine off-label for my situation, and what does that mean for my coverage?
- Does the evidence for this medicine come from people like me, such as healthy adults without diabetes?
- How will we know if this medicine is helping, and what would count as a bad result?
- Should I avoid any surgery, imaging contrast or procedure while taking this medicine?
- Is it safe for me to take this medicine with my other prescriptions and supplements?
- What should I do if I want to stop or change this medicine before our next visit?
Lab and visit tracker
Record each test and visit so you can compare results over time.
| Date | Test or visit | Result | Next due |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.