HealthRX.com · Printable side-effect diary
Enclomiphene citrate side effect diary for prescriber visits
Use this sheet to record any headache, hot flushes, nausea, muscle spasm, blurred vision or mood changes you notice while taking enclomiphene citrate. Bring the completed sheet to your prescriber or pharmacist, or keep it at home.
Your medicine and prescriber details
Write what is on your prescription label or in your records.
Name of medicine as written on labelEnclomiphene citrate or other name on the label
Dose strength and how often you take itCopy from your label exactly
Date you started this medicine
Prescriber name and phone number
Pharmacy name and phone number
Other medicines or supplements you takeInclude any clomiphene you have taken before
Gather before your visit
Bring these so the visit is based on accurate information.
- Bring the medicine box or bottle so the label can be read.
- Write down every side effect in the log, even if it seems minor.
- Note whether any vision change, such as blurring, spots or flashes, has happened.
- Bring a list of any clomiphene or other fertility or hormone medicines you took before.
- Confirm which lab tests your prescriber has planned and when they are due.
- Check with your pharmacist whether any new over the counter medicine affects your plan.
Daily side effect record
Record each day you notice a symptom. Write none if nothing happened.
| Date | Side effect noticed | How strong it felt | Did it stop or continue | Notes |
|---|---|---|---|---|
Questions to ask your prescriber or pharmacist
- Which side effects are most often reported with this medicine?
- Have side effects been reported differently for people with my health profile?
- Which symptoms should make me contact you before my next visit?
- What should I do if I notice any change in my vision?
- Is there monitoring such as eye checks or blood tests you recommend for me?
- How does this medicine compare with clomiphene for side effects?
- Is this medicine approved for my use, or is it being prescribed off label?
- What should I do if I want to stop taking it?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.