Menstrual Chart

Menstrual Chart

Patient Name: ___________________________________________________

Date: ___________

**Length of cycle (days or months): _____________

***Duration of menses (bleeding / number of days): _______________

RECORD ACTIVITY DURING MENSTRUAL CYCLE

– Include additional signs or symptoms throughout the month in the ‘Additional Comments’ section below

Premenstrual

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Post Menstrual

Activity

Activity

Headache (Y/N)

Pain location / (1-10)*

Menstrual Pain (Y/N)

(1 – 10)*

Bloating (Y/N)

Cravings (Y/N) / Type

Clot (Y/N) / Size

Spotting (Y/N)

Pad Changes per day

Breast Tenderness (Y/N)

Location / (1-10)*

Menstrual Color

Menstrual Flow

(light, medium, heavy)

Weight Gain (Y/N)

Feelings/Emotions

* pain scale – 1-3 – mild pain / still able to function; 4-6 –strong pain / ability to function has diminished; 7-9 – extreme pain / unable to function; 10 – worse pain ever experienced

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** length of cycle – 1 cycle = begins 1

day of menstrual period and ends 1

day of the next menstrual period

*** duration of menses – count the days of menstrual bleeding (period) when a flow is established and exclude days of spotting before and after period

Note: If bleeding causes the changing of more than 1 pad per hour – contact your doctor right away.

Additional Comments:

Nature’s Healing – Christopher Carlow, D. Ac. – 401-219-6446