HealthRX.com · Printable side-effect diary
Vyleesi side effect diary and visit checklist
Use this sheet to record your health history and track side effects of bremelanotide (Vyleesi) after each dose. Bring the completed sheet to your prescriber or pharmacist before or after a visit.
Your health details before starting
Write what you already know. Your prescriber can confirm the details.
Blood pressure historyWrite recent readings and any high blood pressure diagnosis
Heart or blood vessel conditionWrite any known cardiovascular condition or family history
Liver condition or past liver testsWrite any liver problem or abnormal liver result you know of
Skin tone and past skin changesWrite any past dark patches on face, gums or breasts
Pregnancy or contraception planWrite your current contraception method
Oral medicines you takeWrite each name, including any naltrexone product
Symptom tracker after each dose
Record the day of each injection and how you felt in the hours and days after.
| Day | Nausea | Flushing | Headache | Skin change | Other notes |
|---|---|---|---|---|---|
Before your visit
- Bring this completed sheet and your tracker to the appointment.
- Bring the medicine guide that came with your Vyleesi pack.
- Note any blood pressure readings taken at home or at a pharmacy.
- List every oral medicine and supplement you take, including naltrexone.
- Check with your pharmacist which product you received and its name on the label.
- Write down any symptom that has not gone away between doses.
Questions to ask your prescriber or pharmacist
- Am I affected by the cardiovascular contraindication or the high risk warning?
- How should my blood pressure be checked while I use this medicine?
- Which of my current oral medicines could interact with Vyleesi?
- What should I do if nausea becomes persistent or severe?
- What should I do if I notice new darkening of my skin?
- What signs of liver problems should I report to you?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.