HealthRX.com · Printable medication review sheet
Bremelanotide and AOD peptide stack review for your prescriber
Use this sheet to record a bremelanotide (Vyleesi) and AOD peptide combination, list what you take and what you have been tracking, and bring it to a prescriber or pharmacist. It is for gathering information and asking questions, not for making treatment decisions.
Medicines and product details
Write exactly what is on each label or package. Note whether a product is prescribed, compounded or research-use.
Bremelanotide product name and sourceFor example Vyleesi from a pharmacy, or a compounded or research-use product
Who prescribed or supplied itName of clinic, pharmacy or website seller
AOD peptide product name and sourceName on the vial or package and where it came from
Batch or lot code on each productCopy from packaging
Other medicines, supplements or alcohol useInclude oral naltrexone products if any
Known heart, blood pressure or kidney conditionsDiagnoses and who manages them
Gather before the visit
Bring this sheet and the items below.
- Bring all product packaging, labels and inserts for each medicine
- Bring your home blood pressure and heart rate readings from the log
- Write the names of all prescribers and pharmacies you use
- Confirm whether you have a current blood pressure reading from a clinic
- Note any prescription or over-the-counter medicine taken in the last month
- Check the label for any boxed warning or REMS statement
- Bring a list of any nausea, flushing, headache or skin changes you noticed
Home tracking between visits
Record each dose and symptom on the day it happens. Write unknown values as unknown.
| Date and time | Product and dose taken | Blood pressure reading | Nausea or headache | Skin darkening or flushing |
|---|---|---|---|---|
Questions to ask
- Does my blood pressure meet the label requirement before starting bremelanotide?
- How often should my blood pressure be checked while I use bremelanotide?
- Is there any labeled interaction between bremelanotide and my other medicines?
- Could bremelanotide reduce absorption of my oral medicines or antibiotics?
- Is there any approved product or monitoring plan for combining these peptides?
- What signs of an adverse reaction should I report to you right away?
- What should I do if skin darkening appears on my face, gums or breasts?
- Is my AOD peptide product FDA approved or compounded, and is it lawful for my use?
- Does my insurer or pharmacy cover either product?