HealthRX.com · Printable medication review sheet
Vyvanse safety signals review sheet for visits
Use this sheet before a prescriber or pharmacist visit about Vyvanse (lisdexamfetamine). Fill in your medicine details, gather the heart, mental health and interaction information listed, track symptoms between visits and bring your questions.
Your Vyvanse details
Copy these from your medicine bottle or pharmacy label.
Medicine name on labelFor example Vyvanse, lisdexamfetamine or a chewable or oral form
Condition it was prescribed forADHD, binge eating disorder or other
Prescriber name and phone
Pharmacy name and phone
Date the medicine was started
Controlled substance refill datesWrite the dates your refills were filled
Gather before the visit
Bring this sheet and everything listed below.
- Bring the current medicine bottle or box with its label
- Write your heart history, including any structural heart problem
- Write any family history of sudden death or heart rhythm problems
- Note any history of psychosis, mania, bipolar disorder or Tourette's syndrome
- List every other medicine, supplement and herbal product you take
- Note any antidepressant, migraine, pain or antibiotic medicine you use
- Write any history of circulation problems in fingers or toes
- Confirm how you store the medicine and how you plan to dispose of unused doses
- Note any recent surgery, dental work or imaging test planned
Symptoms and side effects between visits
Record new or changing signs and how they affected daily life.
| Date | Symptom or sign | How strong | Told who |
|---|---|---|---|
Questions to ask
- Which label warnings apply to my condition and my health history?
- How often will my blood pressure and pulse be checked?
- Should my height and weight be tracked if I am a child or teen?
- Which of my current medicines or supplements could interact with Vyvanse?
- What signs of mood or psychotic change should prompt a call?
- Is Arynta oral solution a different product from my current form?
- What should I do if I notice color changes or sores in my fingers or toes?
- How will my need for this medicine be reviewed over time?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.