HealthRX.com · Printable medication review sheet
Saxenda label and stopping rule review sheet
Use this sheet before a prescriber or pharmacist visit to review Saxenda approval status, label weight checks, the stopping rules and your own weight and side effect record. Bring it along.
Saxenda details to confirm
Copy these from the label, product information or prescription.
Country or region of labelFor example US or EU
Application or product numberCopy from the label or product information
Label or product information dateWrite the effective date shown on the document
Current prescribed doseWrite the dose and the date it started, from your prescription
Weight at start of treatmentUse the unit your clinic uses
Gather before the visit
- Bring the current Saxenda label or product information from an official source
- Write down the date you started Saxenda
- Confirm whether pregnancy is possible or planned
- Check with your pharmacist which liraglutide products you have been given
- Bring the weight and side effect log from this sheet
Weight and side effect record
Weigh at the same time and in the same way each time. Write what you notice.
| Date | Weight | Dose taken | Side effects | Notes |
|---|---|---|---|---|
Questions for your prescriber or pharmacist
- Does the current label for my country match the dose I am taking?
- Based on my weight so far, does the label's stopping rule apply to me?
- Will my weight be checked against the stopping rule, and when?
- Which weight loss target applies to my age and body mass index?
- Do my thyroid history or family history affect whether I should continue?
- Is there a generic liraglutide product that is approved for my use?
- What should I do if I cannot tolerate my current dose?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.