HealthRX.com · Printable side-effect diary
Enclomiphene delayed side effect diary and prescriber visit sheet
Use this sheet to record which enclomiphene or clomiphene product you were given and to track any symptoms over time, including vision, heart, clot, mood and blood-count concerns. Bring it to your prescriber or pharmacist.
Product and treatment details
Write what is on your paperwork. This sheet does not replace medical advice.
Name on the product or prescriptionEnclomiphene, clomiphene citrate or Clomid
Prescriber or clinician name
Date treatment stopped, if it has
Any other medicines or supplementsList each name
Bring to the visit
Gather these before you see your prescriber or pharmacist.
- Bring the label or leaflet for the product you were given.
- Bring this sheet with the symptom log filled in.
- Note any blurred vision, spots or flashes and the date they started.
- List any leg swelling, chest discomfort or breathlessness you noticed.
- Write down any mood changes, irritability or aggression you noticed.
- Confirm which product and name the pharmacy is supplying.
- Check with the prescriber whether any blood or hormone tests were arranged.
- Bring a list of your recent results if you have had blood tests.
Symptom tracking log
Record each day anything new or different, even if it seems minor.
| Date | Symptom | Vision change | Heart or leg change | Mood change | Notes |
|---|---|---|---|---|---|
Questions to ask
- Which enclomiphene or clomiphene product am I being given?
- Which eye check do you recommend if I notice any visual changes?
- Which heart, clot or blood tests are planned while I am on treatment?
- How long after stopping should I keep watching for symptoms?
- Which side effects should I report to you straight away?
- Does my other medicine or supplement list change anything you have advised?
- What should I do with the symptoms I have already written down?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.