HealthRX.com · Printable side-effect diary
Spironolactone side effect and potassium visit sheet
Use this sheet before a visit about spironolactone, whether for acne or another prescribed use. Fill it in by hand, track side effects and potassium questions, then bring it to your prescriber or pharmacist.
Medicine and prescriber details
Write what you know. Leave blank anything you cannot find.
Spironolactone label nameWrite the name and strength printed on the pharmacy label
Reason for taking itWrite the condition the prescriber named
Prescriber name
Pharmacy name and phone
Kidney or liver conditionsWrite any diagnosis you have been given
Other medicines and supplementsWrite every item, including over the counter products
Gather before the visit
Bring this sheet and the items below.
- Bring all medicine bottles and supplement containers
- Note any potassium supplements or potassium salt substitutes in use
- List pain relievers you take, including anti-inflammatory types
- Check with the pharmacist which heart or blood pressure medicines you take
- Confirm the date of your most recent potassium blood test
- Note when your last period started and any changes since starting
- Write any breast tenderness or swelling and when it began
- Confirm with the clinic what potassium test schedule applies to you
Symptom and side effect tracker
Record each change as it happens, using your own words for how bad it felt.
| Date | Symptom | How bad it felt | Shared with prescriber |
|---|---|---|---|
Questions for the prescriber or pharmacist
- Which of my conditions or medicines could change my potassium result?
- How often should my potassium be checked while I take this medicine?
- Do any of my current medicines raise potassium?
- Which side effects should I report to you first?
- Could a combined birth control option change menstrual side effects?
- How should I tell you about breast tenderness or swelling?
- What should I do if I might become pregnant while taking this medicine?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.