The calendar (available through the link below) is designed to give you and your doctor a better idea of your symptoms, their severity, and how long they last.
Before you go to bed each night, reflect on your day. Think about the symptoms you may have had (headaches, angry outburts, anxiety, etc.) and record them in the spaces provided.
You will be asked to rate the symtpoms on a scale of 0-3.
How to fill out the chart:
Cycle day: Begin your calendar on the first day of your menstrual period. This is day #1 of your cycle.
Date: Fill in the calendar date that corresponds with the first day of your period in the box provided. Continue the calendar until your next period starts. Your doctor may have asked you to keep track for a few months, so start a new calendar with each period.
Bleeding: Shade the box in completely (?) for each day of bleeding. Mark an "X" in the box for spotting.
Weight: Check your weight in the morning, before breakfast. Record your weight in the space provided.
Symptoms: Indicate the severity of your symptoms by using the scale provided. Rate your symtpoms at about the same time each evening. Be sure to take into account your symtpoms as the day progressed.
Medications: List any medications that you take in the spaces provided. Mark and "X" for each day the medication is taken.
Other symptoms: If there are other symptoms that you notice, please state what they are in the space provided and rate them as you would other symptoms.
Rating your symptoms:
0 = None. Symptoms are not present.
1 = Mild. Symptoms are noticeable but not troublesome.
2 = Moderate. Symptoms interfere with normal activities.
3 = Severe. Symptoms are intolerable, you are unale to perform normal activities.
Feel free to print these instructions, then print the symptom log through the link below. Brink your symptom log to your next scheduled appointment to review with your health care provider.
