HealthRX.com · Printable side-effect diary
Bremelanotide side effect diary
Use this sheet to record your Vyleesi (bremelanotide) doses and side effects, then bring it to your prescriber or pharmacist. It helps you track nausea, flushing, headache, injection site reactions and skin changes over time.
Your medicine and prescriber
Fill this in once before your first dose.
Product name on the box or penWrite exactly what the label says
Form you receivedFor example autoinjector or compounded vial
Prescriber name and phone
Pharmacy name and phone
Date you started
Other medicines and supplementsInclude anything taken for nausea
Gather before the visit
Bring this sheet to every appointment.
- Write the product name and form exactly as shown on your box or label.
- Bring this diary with every dose and symptom you noted.
- List every other medicine, supplement and anti-nausea medicine you take.
- Note any blood pressure readings you have, including from a home monitor.
- Note any heart or blood pressure conditions your prescriber may not know about.
- Confirm who made your product and where it was obtained.
- Check with your pharmacist whether your insurer needs any approval step.
- Note any doses you skipped or stopped, and the reason for each.
Dose and symptom tracker
Record each dose on the day it happens. Write none for a symptom you did not have.
| Date and time | Nausea (none, mild, moderate, severe) | Flushing | Headache | Injection site | Notes |
|---|---|---|---|---|---|
Questions to ask your prescriber
- Which side effects should make me stop treatment and call you right away?
- Should I check my blood pressure at home, and how often should I write it down?
- What should I do if nausea starts after a dose rather than before it?
- How will you check for skin darkening on my face, gums or breasts?
- Does my heart or blood pressure history change whether this medicine is right for me?
- Is my product the FDA-approved autoinjector or a compounded version?
- What is the plan if injection site reactions keep happening?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.