Symptom Tracker

Use this chart to track your symptoms

MONTH: _______________________

Daily,pleaseindicatetheseverityofsymptomsasfollows:
0 = None/Not applicable
1 = Mild, does not interfere with activities
2 = Moderate, interferes with activities but is not disabling
3 = Severe, disabling

Pleaserecordmenstrualflowusingthefollowingdescriptionsiftheyapply:
H=heavy, M=medium, L=low, B=brown spotting
First day of cycle is first day of bleeding
Day
Symptom
1 2 3

Menstrual Flow
Acne

(H, M, L, B)

Fatigue and/or lack of energy

Joint and/or muscle pain
Headaches
Backaches

(if it's a migraine use 'M' instead of '3')

Cramps and/or pelvic pain

Breast swelling and/or tenderness

Upset stomach

Food cravings (salt, foods high in sugar, chocolate)

Bloating or sensation of temporary weight gain
Constipation
Diarrhea

Difficulty concentrating or remembering things

Trouble sleeping or sleep more than usual

Feeling overwhelmed,outofcontrol, or mood swings

Decreased interest in usual activities

Feeling "on edge", angry, irritable, anxious or "wired"

Feeling depressed or hopeless
Feeling tearful or crying easily
Other Symptom:
Other Symptom:
Other Symptom:
Other Symptom:
Other Symptom:

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