HealthRX.com · Printable medication review sheet
Metformin stopping and PCOS medication review sheet
Use this sheet before a visit about stopping, continuing or changing metformin for PCOS. Record your medicine details, gather kidney and vitamin B twelve results, track stomach symptoms and write questions for your prescriber or pharmacist.
Current metformin details
Write what is on your pharmacy label and your own notes.
Medicine name and formImmediate or extended release, as on the label
Reason it was prescribedYour own words, such as PCOS or another reason
Date you started
Prescriber name and contact
Pharmacy name and contact
Planned change being discussedStop, continue, pause or switch
Before the visit
Bring these to your appointment.
- Bring the medicine bottle or pharmacy label
- Write down any recent kidney function results
- Gather recent vitamin B twelve and blood count results
- Note any planned scan or procedure that uses contrast dye
- Note any illness that affects eating, drinking or vomiting
- List every other medicine and supplement you take
- Check with your pharmacist about interactions with your other medicines
Stomach and energy tracker
Record what you notice each day or week. Do not change your dose on your own.
| Date | Stomach symptoms | Food and fluid intake | Notes for prescriber |
|---|---|---|---|
Questions for your prescriber
- Is metformin still the right treatment for my PCOS goals?
- What should I expect with my periods or ovulation if I stop it?
- How often will my vitamin B twelve level be checked?
- Which blood tests are needed if I continue or stop?
- Do any of my kidney results mean a change is needed?
- What should happen with this medicine before a scan with contrast dye?
- What plan should I follow for pregnancy prevention while I take it?
- Can my pharmacist review how this medicine fits with my other medicines?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.