Name: Ms_______________________________________________________ Age: ______
Menarche: ____yr. Treatment on:______________________
Menstrual flow - grading
Mild + Moderate ++ Severe +++ More than 1 pad per hour ++++
For every day that you bleed mark with a (+) depending on the flow preferably with Red ink. For every day that you do not bleed, put a (X).
This chart will help your doctor, understand at a glance, your menstrual irregularity.