HealthRX.com · Printable medication review sheet
Zepbound function and medication review for older adults
Record the treatment goal, a baseline for walking, getting up, falls, eating and drinking, and the medicines that change the risk, then log changes between visits. Bring it to each review so a change in function or hydration is weighed against the benefit, rather than age alone.
Treatment goal and current dose
Reason for treatmentweight-related condition, sleep apnea, other
The benefit that matters most to you
Current weekly dose and date of the last increase
Who reviews progress, and when
Baseline function before or at the start
Write what is usual for you now, so later changes are easy to spot.
Walking distance and stairs
Getting up from a chair without using your armsyes / with effort / no
Falls or near-falls in the past year
Help needed with shopping, meals or medicines
Usual appetite and meals per day
Usual daily drinks, and any fluid limit you have been given
Medicines and conditions to review together
- Insulin
- A sulfonylurea or another insulin secretagogue
- Blood pressure medicines
- A diuretic (water pill)
- Chronic kidney disease or a recent abnormal kidney test
- Heart failure or a fluid restriction
- Osteoporosis or a previous fracture
- Trouble seeing the pen or handling an injection
Changes between visits
Only note what changed. A new fall, new weakness or poor intake is worth a call even if weight is going the right way.
| Date | Weight | Walking, chair rise or a fall | Eating and drinking | Dizziness or blood pressure | Stomach symptoms |
|---|---|---|---|---|---|
What the Zepbound label says
- In the pooled weight trials, 226 Zepbound-treated people (9%) were 65 or older and 13 (0.5%) were 75 or older.[1]
- Hypotension affected 2.2% of Zepbound-treated people on blood pressure medicine and 1.2% of those not on it.[1]
- Kidney function should be checked when side effects could lead to dehydration, especially while starting or increasing the dose.[1]
- No Zepbound dose change is recommended for kidney impairment alone.[1]
- With insulin or a sulfonylurea, the risk of low blood sugar rises, and a lower dose of those medicines may be needed.[1]
- The KwikPen is not recommended for people with impaired vision to use on their own.[1]
Call the care team promptly, or get urgent help
- Nausea, vomiting or diarrhea that persists: the fluid loss can cause kidney problems.[1]
- Dizziness, light-headedness, confusion or drowsiness in someone using insulin or a sulfonylurea (possible low blood sugar).[1]
- Fainting, or swelling of the face, lips, tongue or throat with trouble breathing or swallowing.[1]
- Abdominal pain that is severe or keeps going, sometimes spreading to the back.[1]
Questions for the next review
- Is the original reason for treatment still the main goal, and is it being met?
- Should any blood pressure medicine, diuretic, insulin or sulfonylurea dose change now?
- Which change in walking, getting up from a chair, or a fall should make me call?
- Would a slower dose increase or a lower labeled maintenance dose suit me better?
- Do I need a kidney test now, given any vomiting, diarrhea or poor intake?
- Do my own conditions call for a bone density, nutrition or strength assessment?
Sources for the facts on this sheet
- Eli Lilly and Company, via DailyMed. Zepbound (tirzepatide) injection, for subcutaneous use: prescribing information and Medication Guide. Effective 2026-08-28. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.