This tool can also be useful to show your doctor to discuss any questions or concerns you might have. Print this form out every month or print multiple copies now, answer the questions after your period and compare to other months.

Automatically select a date by clicking on the calendar icon.

What was the start date of your period this month?  

What was the end date of your period this month?   

 
How many tampons/pads were fully saturated each day of your period?

 
Did you miss any days of work because of your period this month?    Yes  No
 
If you answered Yes, how many days did you miss?
Date(s):

 
Did you miss any social activities because of your period this month? Yes No

Which ones? (Select dates.)

Event	Date

 
Did you feel especially weak or fatigued during your period this month? Yes    No

Date(s):

Symptoms:

 
Did your period disrupt your sexual activity because it was so heavy this month? Yes No