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.
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