HealthRX.com · Printable medication review sheet
Viagra and PPI medication review sheet for omeprazole or pantoprazole
Use this sheet before a visit with your prescriber or pharmacist when you take sildenafil (Viagra) together with a proton pump inhibitor such as omeprazole or pantoprazole. Fill it in by hand, bring it along, and keep a copy at home.
My medicines and habits
Write what you take now, including products bought without a prescription.
Sildenafil (Viagra) prescribed byName of the prescriber who started it
Proton pump inhibitor nameOmeprazole, pantoprazole or another, exactly as on the bottle
Form and strength on the bottleCopy the wording from the label
Other prescription medicinesName each one and who prescribed it
Over the counter products and supplementsInclude any heartburn or pain relief products
Alcohol useWrite how often and roughly how much
Grapefruit or grapefruit juiceWrite how often you have it
Before the visit
Tick each item when it is done.
- Bring all pill bottles and boxes, including over the counter products
- Confirm the exact name and form of your proton pump inhibitor with your pharmacist
- Write down the chemist's wording for any new medicine added since your last visit
- Note any nitrate or alpha-blocker medicines you take, and check with your prescriber that they are listed
- Check with your pharmacist that your full medicine profile is up to date
- Bring the leaflet that came with your Viagra if you still have it
- List the questions below that you want answered before you leave
- Note the emergency signs your prescriber described to you and write them on the back of this sheet
Questions to ask
- Does the Viagra label list my proton pump inhibitor as an interaction?
- Is there any reason my Viagra dose should be changed while I take omeprazole or pantoprazole?
- Would switching from omeprazole to pantoprazole make any difference for my Viagra prescription?
- Should I tell you about any new medicine, even one I only take sometimes?
- Does grapefruit or alcohol change how Viagra works for me?
- Which side effects should I report to you right away?
- What should I do if I have a long or painful erection?
- Can you check my full medicine list with the pharmacy before my next refill?
Week by week medicine and symptom record
Write the date each time you take a dose or notice a change.
| Date | Viagra taken | PPI taken | New symptoms or 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.