HealthRX.com · Printable question sheet
Metformin for weight maintenance questions for your prescriber
Use this sheet before or during a visit about off-label metformin for weight maintenance. Fill in your medicine details, gather your records, ask the questions, and track symptoms and weight between visits.
My metformin details
Write what is on your pharmacy label or prescription. Leave blank if unknown.
Medicine name on labelGeneric or brand, such as Glucophage
FormImmediate-release or extended-release, as written
Prescriber name and clinic
Pharmacy name and phone
Reason for weight use discussedNote the diagnosis or insulin resistance result you were given
Other current medicines
Bring or confirm before the visit
- Bring your most recent kidney function test results
- List your liver test results and any alcohol use to share
- Note any planned IV contrast scans or surgery and their dates
- Confirm whether your pregnancy plans have been discussed
- Check with your pharmacist whether an extended-release form is available
- Bring your home weight notes and symptom log from the tracker below
Questions to ask your prescriber
- Is my use of metformin for weight off-label, and what is the reason for it?
- What weight change should I realistically expect, and how long before I would notice it?
- What dose range are you considering, and how will it be adjusted over time?
- What should I do about this medicine before and after any contrast imaging?
- What symptoms should prompt me to call the clinic or seek urgent care?
- When will we review whether this medicine is still helping me?
Symptom and weight tracker
| Date | Stomach symptoms | Other symptoms | Weight noted | Questions for next visit |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.