HealthRX.com · Printable medication review sheet
Bremelanotide and Vyleesi product review sheet
Use this sheet before a visit or pharmacy call about bremelanotide, Vyleesi, research-use or compounded products. It helps you record what you have, where it came from and what to ask before any decision.
Product in hand
Copy this from the box, vial, label or order form. Write unknown if you do not know.
Name printed on the labelExact wording, such as PT, bremelanotide or Vyleesi
Where it was bought or orderedSeller, clinic, online site or pharmacy name
Does the label say FDA-approvedWrite yes, no or not stated
Does the label say research use onlyWrite yes, no or not stated
Pharmacy name and phone on the label
Lot or batch wording on the label
Prescriber name, if one was given
Before the visit or pharmacy call
Gather these items so the conversation can be checked against the label.
- Bring the box, vial or autoinjector with its original label
- Bring any prescription, order form or receipt for this product
- Write down every name the product has been sold under
- Note whether the product was prescribed, ordered or bought as research use
- Confirm the label names bremelanotide or Vyleesi and who makes it
- Check with the pharmacy whether it is a compounded product
- Bring a list of other medicines, supplements and anything taken near the same time
Questions to ask your prescriber or pharmacist
- Is the product in my hand the FDA-approved bremelanotide product?
- Is this product prescribed for my situation under the approved label?
- Which pharmacy prepared this product, and is it a compounded drug?
- Does the pharmacy hold a valid prescription for me to receive it?
- What information about the product's quality testing can you share?
- Should I continue using this product while we review these questions?
- What signs would you want me to report to you before my next visit?
Record of use and reactions
Write one line for each use. Bring this log to every follow-up visit.
| Date | Skin or flushing noticed | Nausea or headache | Notes for prescriber |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.