Menstrual Assessment Chart
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1Menstrual Assessment Chart
Date of start ______________________
Directions
Keep a tally of the number of pads
Day
1
2
3
4
5
6
7
8
9
10
11
12
or tampons you use each day of
Pads
your cycle and their level of
saturation. Also take note of clots
Lightly soaked
or overflow. Clots >1 cm in size
are considered large.
Scoring
Moderately soaked
Pads (score per pad)
Lightly soaked:
1 point
Moderately soaked: 5 points
Heavily soaked
Heavily soaked:
20 points
Tampons (score per tampon)
Lightly soaked:
1 point
Moderately soaked: 5 points
Clots
Heavily soaked:
10 points
(small or large)
Clots
Tampons
Small:
1 point
Lightly soaked
Large: 5 points
INTERPRETATION
A score of ≥ 100 points indicates
Moderately soaked
probable menorrhagia.
Contact your doctor or the
nearest bleeding disorder
Heavily soaked
treatment centre if you are
concerned about your menstrual
bleeding.
(
Clots
centres)
(small or large)
Score
Total score: __________
Source: Jenny M. HIGHAM, P. M. S. O’BRIEN, R.W. SHAW, Assessment of menstrual blood loss using a pictorial chart,
British Journal of Obstetrics and Gynaecology, August 1990, Vol. 97, pp. 734‐739
Canadian Hemophilia Society 2015
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