A page for the things you want to say.
Free printable GLP-1 appointment checklist
Bring your questions into the room. Use this blank worksheet before and during a visit with your prescriber, pharmacist or dietitian.
Choose Print or Save as PDF. Use portrait A4 or US Letter, default margins and turn off browser headers and footers. No signup or email needed.
Write on paper after printing. There are no fields here for entering health information. Keep completed copies private.
JellyPal · Personal record
My appointment notes
Appointment date: Care team:
Bring your current medication list and any records you want to discuss. Complete the last section with your care team.
My priorities
What are the three things I most want to discuss?
What I have noticed
What has changed, when did it start, and how has it affected my day?
My questions
What do I want to ask about my prescription, eating, daily routine or costs?
Next steps agreed with my care team
What did we decide together? Who should I contact with questions, and when is my next visit?
For organizing a conversation, not medical advice or a treatment plan. Follow your prescription and your care team’s instructions. Do not wait for an appointment if you need urgent medical help.
Keep completed sheets private. Free blank copies: jellypal.app/glp-1-appointment-checklist
Use it your way
Fill in only what you want to share with your care team. You can bring the blank injection log alongside this sheet.
Read our appointment preparation guide. For general tips on asking questions, see the AHRQ Questions Are the Answer resource.
For patient resource lists and newsletters, use our sharing and linking guide.
Bring your records together
Explore JellyPal for tracking and reminders between appointments.
