HealthRX.com · Printable medication review sheet
Sirolimus and progesterone HRT review sheet
Use this sheet before a visit with your prescriber or pharmacist if you take sirolimus (Rapamune) and progesterone hormone therapy such as Prometrium. Fill it in by hand, bring it along, and track drowsiness or dizziness at home.
My medicines
Copy the names exactly as they appear on each bottle or pharmacy label.
Sirolimus product name and sourceBrand name such as Rapamune, or compounded from which pharmacy
Progesterone product name and formFor example Prometrium capsules, and whether taken at bedtime
Reason for each medicineWrite the condition or goal each prescriber gave you
Other prescriptions, over-the-counter products and supplementsInclude St. John's wort, grapefruit products and any antifungals or antibiotics
Prescribers and pharmacyName, clinic or pharmacy phone number
Bring or confirm before the visit
Ask the pharmacist to check the full list, not only one product.
- Bring every bottle, box or capsule packet you take, including the progesterone product
- Write the exact sirolimus source and whether it is FDA-approved or compounded
- Confirm with the pharmacy that progesterone is on your profile with sirolimus
- Note any new medicine started since your last visit, even short courses
- Check with your prescriber whether any pregnancy or contraception plan applies to you
- Note any dizziness, drowsiness, vision changes or trouble walking since starting either medicine
- Bring this sheet and the drowsiness log below
Questions to ask
- Does the sirolimus label list progesterone as an interacting drug for my dose?
- Does the pharmacist see any interaction between my progesterone and sirolimus?
- Should I tell you if I start or stop any antifungal or antibiotic?
- Is there any reason my progesterone timing should change while on sirolimus?
- Which symptoms should prompt me to call you the same day?
- Does my progesterone plan still apply if I am still in perimenopause?
- Is there a pregnancy prevention plan you want me to follow during and after sirolimus?
- Is my sirolimus source approved for my condition or used off-label?
Drowsiness and dizziness diary
Write each day you notice a change. Note the time of your progesterone dose and any driving.
| Date | Progesterone taken | Dizziness or drowsiness | Driving or machinery use |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.