HealthRX.com · Printable medication review sheet
Spironolactone and SNRI medication review sheet
Use this sheet to write down your spironolactone and SNRI medicines (venlafaxine or duloxetine), track the blood pressure, potassium and sodium results you receive, and prepare questions for your prescriber or pharmacist before a visit.
Your current medicines
Copy these from your pill bottles or pharmacy label.
Spironolactone: strength and how often takenAs written on the label
Date spironolactone was started or changed
SNRI nameVenlafaxine or duloxetine, plus any brand name
SNRI strength and how often taken
Potassium supplements or salt substitutes used
Lithium, ACE inhibitor or ARB, if anyName only what you take
Other medicines, herbal products and supplements
Pharmacy name and phone
Before your visit
Bring this sheet to every appointment.
- Bring all pill bottles and any herbal products or supplements you take.
- Write down recent home blood pressure readings in the table below.
- Confirm the dates and results of your most recent potassium and sodium tests.
- Note any dizziness, fainting or falls since your last visit.
- Check with your pharmacist whether any new medicine you were offered is on your list.
- List any new symptoms such as confusion, muscle twitching or unusual tiredness.
Questions to ask
- Which of my medicines should I watch most closely for potassium or sodium changes?
- How often do you want my potassium and sodium checked while I take both medicines?
- Should my blood pressure be checked more often now, and what readings should I report?
- Does my SNRI dose change how my blood pressure should be monitored?
- Which over-the-counter pain relievers, salt substitutes or supplements should I check with you about first?
- What symptoms should prompt me to call the office or seek urgent care?
Blood pressure and lab results
Record each reading or result with the date it was taken.
| Date | Blood pressure | Potassium result | Sodium result | Notes |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.