HealthRX.com · Printable question sheet
Low-dose naltrexone side effects questions for your prescriber
Use this sheet before starting, changing or stopping low-dose naltrexone. Write down your medicine details, bring the right information to the visit, ask about side effects, possible permanent effects, liver checks and opioid withdrawal risk, and track any symptoms at home.
Your current medicine details
Fill in before the visit. Keep a copy with your medicine list.
Medicine name and strengthWrite exactly as it appears on the label
Prescriber nameDoctor or nurse practitioner
Pharmacy nameInclude whether it is a compounding pharmacy
Date treatment startedWrite the day, month and year
Opioid medicines taken now or recentlyInclude pain pills, methadone, buprenorphine and any opioid cough or diarrhea product
Alcohol useWrite how you use alcohol, if at all
Bring or confirm before the visit
Bring these to your prescriber or pharmacist.
- Bring all medicine bottles, including over-the-counter cough, cold and antidiarrheal products
- List every opioid you have taken, even if only occasionally
- Confirm whether your LDN is made by a compounding pharmacy
- Note any recent blood tests, especially liver tests, and bring copies
- Write down any mood changes, sleep problems or thoughts of self harm to share
- Confirm who to call after hours if a symptom gets worse
- Check with your pharmacist which pain relief options your medicine list allows
Ask your prescriber or pharmacist
- Which side effects listed in this article should I watch for first?
- Could any side effect I notice be permanent, and how would we know?
- How will you check my liver while I take this medicine?
- What withdrawal signs should I watch for if I still use opioids?
- What pain relief plan should I follow if I need opioid medicine during treatment?
- How will we review my mood and sleep during treatment?
- Is my LDN product FDA approved, and how is its quality checked?
Symptoms and side effects by day
Write each symptom as it happens. Bring this log to every visit.
| Date | Symptom or side effect | How strong it felt | Other medicine taken | Still present |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.