HealthRX.com · Printable medication review sheet
Levothyroxine and lithium review for TSH stability
Use this sheet before a visit when lithium or another medicine is added, stopped or changed while you take levothyroxine, or when your TSH results move unexpectedly. Bring it to your prescriber or pharmacist.
Current medicines and timing
Write what you take now. Include supplements, antacids and products bought without a prescription.
Levothyroxine product and formBrand, tablet, liquid or gel-cap
Lithium product and start dateName as printed on the label
Other prescribed medicinesName and who prescribed each
Calcium, iron or antacid productsName and how often you take them
Time you take levothyroxineWrite the usual time and what you take it with
Coffee, food or drink near your doseWrite when you usually have them
Gather before the visit
Bring the printed sheet and these items.
- Bring all bottles and boxes of levothyroxine and lithium
- Bring a list of every supplement and over-the-counter product
- Bring your most recent TSH result and the date it was taken
- Note the date of any recent change to lithium or levothyroxine
- Check with your pharmacist that all medicines appear on one profile
- Write down any change in energy, weight, mood or heart rate since the last test
- Confirm the date of your next scheduled TSH test
Questions to ask at the visit
- How often should my TSH be checked while I take lithium?
- Should my TSH be rechecked after lithium is started or stopped?
- Would a liquid or gel-cap levothyroxine form suit my routine?
- Do any of my other medicines affect how levothyroxine is absorbed?
- How far apart should levothyroxine be from my calcium, iron or antacid?
- Should my lithium or levothyroxine be checked if I start a new medicine?
- Who should I contact if my TSH result changes before my next test?
TSH and medicine change tracker
Record each test and any change to medicines between tests.
| Date | TSH result | Medicine change | 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.