Female Cycle Symptom Diary Equilibria printable pdf download

Female Cycle Symptom Diary Equilibria

Name:_______________________

Menstrual Cycle Symptom Diary

Date of Birth:______________

Please fill in this form daily, placing a cross in the box for each symptom experienced that day.

Day of cycle: 1

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:

mood and brain

Depression, feeling down

Anxious, nervous, worrying

Mood swings - irritable, teary, easily upset

Difficulty concentrating, poor memory

Poor sleep, broken sleep, insomnia, oversleeping

physical

Fatigue, tiredness, lack of motivation

Digestive upset, diarrhoea, constipation, bloating

Abdominal pain, back pain

Skin changes, rashes, pimples

Increased or decreased appetite, overeating, cravings

Headaches

Hot flushes, night sweats

Breast swelling/tenderness/pain

Fluid retention

Note: Take saliva/urine samples today

menses

Bleeding

Pain, cramping

Sensation of dragging, heaviness in the pelvis

Presence of clots

Mark down the number of pads or tampons used daily next

to the degree of bleeding pictured:

Pads

Tampons

Please note any change in circumstances: Stressful events, changes in health, medications, any other symptoms (note with date of occurence)

Female Cycle Symptom Diary Equilibria