HealthRX.com · Printable medication review sheet
Zinc and vardenafil medication review sheet
Use this sheet before a visit with your prescriber or pharmacist about taking zinc supplements with vardenafil (Levitra, Staxyn or generic). Fill it in by hand, bring it along, and keep a running record at home.
Your vardenafil and zinc details
Copy these from your bottles and labels. Ask the pharmacist if you cannot read a label.
Vardenafil product name on labelWrite Levitra, Staxyn or generic vardenafil
Vardenafil formFilm-coated tablet or orally disintegrating tablet
Vardenafil strength and directionsCopy exactly from the label
Zinc product nameInclude single zinc or multivitamin with zinc
Zinc amount per day as labeledCopy the elemental zinc amount from the supplement facts panel
Other medicines and supplementsInclude nitrates, alpha-blockers, blood pressure drugs and antibiotics
Prescriber and pharmacy phoneWrite the number you will call
Gather before the visit
Bring these items so the review can be complete.
- Bring every vardenafil and zinc bottle or box you use
- Bring a list of all prescription and over-the-counter products
- Note every zinc product, including multivitamins and lozenges
- Write down any nitrate or nitric oxide donor products you have used
- Confirm which vardenafil form you were prescribed
- Note any dizziness, fainting, nausea or headache you have noticed
- Check with your pharmacist for any recent new prescriptions
- Bring this completed sheet and the log below
Questions to ask at the visit
- Is zinc named as an interaction for my vardenafil prescription?
- Which of my other products should I review with vardenafil?
- How much zinc per day is considered too much for me?
- Should I space zinc away from any of my other medicines?
- What copper or blood symptoms should I report to you?
- Does my blood pressure history change how we should review this?
- Which vardenafil form is safer for my current supplements?
- What should I do if I already took zinc with vardenafil?
Daily zinc and vardenafil record
Write each day you take zinc or vardenafil. Bring this log to your next visit.
| Date | Zinc product and amount | Vardenafil taken and time | Symptoms noted |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.