HealthRX.com · Printable medication review sheet
Jardiance and metformin interaction review sheet
Use this sheet to prepare for a medication review with your prescriber or pharmacist about taking Jardiance (empagliflozin) with metformin, or Synjardy. Fill it in by hand, bring it to the visit, and keep a copy at home.
Medicines I take now
Copy the names and written strengths from your labels. Do not change anything based on this sheet.
Jardiance (empagliflozin) strength and how oftenCopy exactly from the bottle or prescription label
Metformin strength and how oftenCopy exactly from the bottle or prescription label
Synjardy taken instead of separate tablets?Write yes, no or not sure
Insulin or sulfonylurea also takenWrite the name, or none
Water pill or diuretic also takenWrite the name, or none
Date of most recent kidney function testWrite the date and the name of the test
Gather before the medication review
- Bring all current medicine bottles or boxes, including over the counter products
- Bring the most recent kidney function test results
- Note any upcoming surgery, scans with contrast dye, or dental procedures
- Confirm the name of your pharmacy and the phone number for questions
- List any alcohol use as you honestly report it to your clinician
- Check whether your prescriber has a copy of your full medicine list
- Write down any illness or missed meals since your last visit
Sick days, fasting and procedures
Record each time eating, drinking or health changed, and what the prescriber or pharmacist told you to do.
| Date | Eating and drinking | Illness or procedure | Medicine change advised | Who advised |
|---|---|---|---|---|
Questions to ask at the visit
- Does my kidney function test mean I should keep taking both medicines?
- Which symptoms should make me contact you the same day?
- If I cannot eat or drink, which of my medicines should I pause and when do I restart?
- Should I stop either medicine before a scan with contrast dye or a surgery?
- Would a lower dose of my insulin or sulfonylurea be needed with these medicines?
- Does Synjardy suit me better than taking the two medicines separately?
- How often will my kidney function be checked while I take these 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.