Use this record to describe your periods, symptoms and what has changed. Have the notes you want to discuss available during your appointment. You do not need a complete record, or to track for a set number of days, before asking for help.
Last updated 30 October 2026
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How to use your record
Use one row for a day or an episode you want to remember. Note when bleeding or symptoms started and stopped, if you know. You can record symptoms on days without bleeding too. Approximate dates and short descriptions are fine; leave anything you are unsure about blank.
- Bleeding: describe what you noticed in your own words, such as spotting, lighter or heavier than usual, or no bleeding. If useful, note the period product you used, how often you changed it, and any leaks or clots. You do not need to measure blood loss.
- Pain or other symptoms: note where you felt pain, when it happened and any other changes you want to discuss.
- Effect on daily life: describe what became difficult, such as sleeping, studying, working or exercising.
- What you tried: record any medicine or other measure used, including the dose if known, and whether it helped or caused problems.
This record can help you discuss symptoms. It cannot diagnose their cause and should not be used to prevent pregnancy. Keep completed records somewhere private. Use paper or your own notes and share only what you choose.
My record
| Date / time | Bleeding | Pain or other symptoms | Effect on daily life | What I tried and what happened |
|---|---|---|---|---|
Continue on another sheet whenever useful.
What I want to discuss
The change or concern that matters most to me:
____________________________________________________________
My questions:
____________________________________________________________
Have your medicine and contraception details handy. Tell your clinician if pregnancy is possible, or if bleeding happens between periods or after sex. You can mention these privately during the appointment rather than write them here.
When to seek help sooner
Arrange medical assessment for heavy periods, pain that concerns you, or bleeding between periods, after sex or after menopause. If pregnancy is possible and you have bleeding, seek medical advice promptly.
Seek urgent care for severe abdominal or pelvic pain, especially if pregnancy is possible. If you are bleeding very heavily, or feel faint or close to passing out while bleeding, call 000. Do not wait to finish this record.