Menstrual Cycle Diary / Bbt Chart
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13712 MacArthur Blvd. Ste 208. New Orleans, LA 70114
Tel. 504-362-8020
Menstrual Cycle Diary / BBT Chart
Patient Name: ________________________________
Age: ________
Date: from _______ / _______ / _______ to _______ / ______ / _______
Menstrual Flow
1: Light
2: Moderate
3: Heavy
4: Clots
Grading of Symptoms
1: Mild - present but does not interfere with activities
2: Moderate - present and interferes with activities but not disabling
3: Severe - disabling, unable to function
Cervical Mucus Consistency D: Dry
M- : Thin Mucus
M: Moderate Mucus
M+ : Thick Mucus
P: Pasty
Cervical Mucus Color
C: Clear
W: White
Y: Yellow
G: Green
D: Cloudy
Cervical Mucus Smell
N: Normal / Odorless
F: Foul odor
Day of Cycle
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Date
Day of Week
Menses
PMS Symptoms
Nervous Tension
Mood swings
Irritability
Anxiety
Depression
Forgetfulness
Crying
Confusion
Insomnia
____________________
Headache
Craving for Sweets
Increased Appetite
Heart Palpitations
Fatigue
Dizziness / Faintness
Swelling of Extremities
Breast distention / Pain
Abdominal distention
Diarrhea
Constipation
__________________
Menstrual Pain
Abdominal Pain
Low Back Pain
General Aches / Pain
___________________
Basal Body Temp.
Temperature
Time
Cervical Mucus
Consistency
Color
Smell
Intercourse
Notes: (List any changes to your routine)
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Parent category: Miscellaneous