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.

Date	Month 1	Month 2	Month 3	Month 4	Month 5	Month 6	Month 7