HealthRX.com · Printable medication review sheet
Bremelanotide (Vyleesi) product and dosing review sheet
Use this sheet to record which bremelanotide product you have, where it came from, and what to confirm before any dose. Bring it to your prescriber or pharmacist, or keep it at home for your records.
Product identity
Copy these details exactly from the box, pen or pharmacy label.
Product name on the labelWrite the name exactly as printed
Is it the prefilled autoinjector pen?Write yes or no, and note any vial or powder
Pharmacy or seller nameWrite the pharmacy, clinic or online seller
Lot or batch numberFound on the box or vial
Date you received itWrite the date in your own format
Before the visit
Gather these items before you speak with your prescriber or pharmacist.
- Bring the Vyleesi box or the exact label from any other product
- Write down whether the product is a prefilled pen or a vial needing mixing
- Note the source and seller name for any compounded or research-use product
- Confirm with the pharmacist whether any mixing or syringe measuring is involved
- List any blood pressure or heart conditions you have been told about
- Write down any medicines or supplements you already take
- Check with the prescriber whether an FDA-approved product fits your situation
Dose and reaction diary
Record each use and any reactions you notice afterwards.
| Date | Product used | Nausea | Flushing | Headache | Notes |
|---|---|---|---|---|---|
Questions to ask
- Is the product I have the FDA-approved Vyleesi prefilled pen?
- Does this product need any mixing, and who would measure it?
- How can a vial dose be checked if the label gives no units?
- Is a compounded or research-use product covered by my plan?
- Which blood pressure symptoms should I report to you?
- Would my blood pressure be checked before and after a dose?
- Can you explain what the label says about dosing limits?
- Is it safe to use this product with my other medicines?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.