HealthRX.com · Printable question sheet
Low-dose naltrexone questions for your prescriber or pharmacist
Use this sheet before or at a visit when you are prescribed or considering low-dose naltrexone (LDN), which is off-label and usually compounded. Fill it in, bring it to your prescriber or pharmacist, and keep a copy at home.
Your LDN prescription details
Copy these from the label or pharmacy paperwork. Write what is printed, not what you remember.
Product name as printed on labelFor example naltrexone, or wording on the bottle
Compounding pharmacy name and phonePharmacy that filled the prescription
Strength as printed on labelCopy the exact strength and unit
Form and how it is takenCapsule, liquid, cream or other form
Prescriber name and clinic
Reason for use as discussedCondition you were prescribed it for
Bring or confirm before the visit
Gathering these helps the prescriber check interactions and labels.
- Bring the original bottle or box with the pharmacy label
- Bring a full list of all pain medicines, including any opioids
- List every current and past opioid prescription you have had
- Note any other medicines, vitamins or supplements you take
- Confirm whether any of your medicines contain naltrexone or bupropion
- Write down any liver tests or blood tests you have had recently
- Check with your pharmacist whether the compounder is licensed in your area
- Ask your insurer whether the cost of this product is covered
Questions to ask
- Is this product approved by the FDA for this condition?
- Which label warnings apply to the strength I am being given?
- Are there any opioid medicines I should stop or avoid while using it?
- What signs of liver problems should I report to you?
- Has the compounding pharmacy shown evidence the product is pure and correctly dosed?
- What is the plan if I am not seeing a benefit after the trial period?
- Who should I contact if I have side effects after hours?
- Will you review the decision with me if the research changes?
Effects to track since starting
Write the date, what you noticed and how bad it was. Show this table at each visit.
| Date | What I noticed | How bad (mild, moderate, severe) | Action taken or question |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.