HealthRX.com · Printable side-effect diary
Vardenafil and Levitra side effect diary for prescriber visits
Use this sheet to record your vardenafil medicine details and track headache, flushing, nasal stuffiness, dyspepsia and other reactions over time. Bring it to your prescriber or pharmacist, or keep it at home.
Medicine details from your label
Copy these exactly as printed on your pharmacy label or box.
Medicine name on labelVardenafil, Levitra, Staxyn or other
Tablet formFilm-coated or orally disintegrating
Strength printed on labelWrite the strength exactly as shown
Date you started this medicine
Prescriber name and clinic
Pharmacy name and phone
Before your visit
Gather these items so the visit covers your full picture.
- Bring the medicine box or bottle with its label
- Note which tablet form and strength you take
- List any nitrate medicines you use in any form
- List any alpha-blocker or other blood pressure medicines you take
- Write down any heart rhythm condition or family history of long QT
- Note any eye, vision or hearing changes you have noticed
- Check with your pharmacist about all other medicines and supplements on your list
- Bring this sheet with the diary filled in
Daily side effect record
Write one row each time you notice a symptom, even if it passes quickly.
| Date | Symptom noticed | How strong | Hours after tablet | What helped |
|---|---|---|---|---|
Questions to ask at your visit
- Which side effects on my label should I report first?
- Does my tablet form change how often headache or flushing happens?
- Which of my other medicines could affect my blood pressure with this one?
- Does my heart rhythm history mean this medicine is a poor fit for me?
- What should I do if an erection does not go away after a long time?
- What should I do if I notice sudden vision or hearing changes?
- Who should I call after hours about a side effect?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.