PMDD Chart - WHCC website - St. Joseph's Healthcare Hamilton
Tel: (905) 522-1155 Intake Fax: (905) 308-7220
PMDD Chart
In order to accurately assess your premenstrual symptoms, it is important for us to review the pattern of your symptoms over time.
After you complete 2 months of charting, please call our intake line and leave your contact information to set up your first appointment:
Intake Coordinator: Lisa Botas 905-522-1155 ext. 33979
N.B. As the waiting time for a first appointment can be anywhere between 1-3 weeks, you may wish to call the intake line a few weeks prior to completing your charts so that your scheduled appointment follows closely after chart completion.
INSTRUCTIONS:
1. Beginning tracking your premenstrual symptoms with this chart today, filling it out every day (preferably at the end of your day) until your appointment at the clinic. A full menstrual cycle (28 ? 40 days) of charting will allow for a more accurate assessment.
2. When you have menstrual bleeding, mark this with an "X" in the "Menses" column. When you have "spotting" (very light bleeding), mark this with an "S" in the "Menses" column. When you are not bleeding, leave the "menses" column empty for that day.
3. Every day, rate what you have experienced under ALL of the column headings. Do not look at your ratings from the previous day, (covering previous ratings with another piece of paper is helpful) so that you rate each day individually ? do not rate your day's experience compared to yesterday or previous days.
RATING SCALE:
Not at all = 0
Mild = 1 Moderate = 2
Severe = 3
"Sleep" = rate severity and note increase with "" and decrease with "" "Appetite" = rate severity and note increase with "" and decrease with "" "Physical Symptoms" = symptoms like headache, bloating, cramping, backache, breast tenderness
Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21 Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28 Day 29 Day 30
Menses Depressed Tension Mood
Mood Swings
1st Month Irritable Lack of Difficulty Appetite Sleep
Interest Concentrating
Lack of Physical Energy Symptoms
downloaded from the WHCC website
Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21 Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28 Day 29 Day 30
Menses Depressed Tension Mood
Mood Swings
2nd Month Irritable Lack of Difficulty Appetite Sleep
Interest Concentrating
Lack of Physical Energy Symptoms
downloaded from the WHCC website
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