Prism Calendar, Courtesy of Dr. Robert Reid.

Name:___________________________________
Baseline weight on Day 1:___________ Lbs. or Kg. (circle 1).

Instructions for Completing this Calendar:

1. On the first day of menstruation prepare the calendar: Considering the first day of bleeding as day 1 of your menstrual cycle enter the corresponding calendar date for each day in the space provided below.
2. Each Morning: Take weight after emptying bladder and before breakfast. Record Weight Change from baseline.
3. Each Evening: At about the same time complete the column for that day as described below.
4. Bleeding: Indicate if you have had bleeding by shading the box above that days date ( ). For spotting use an [x].

Symptoms: If you do not experience any symptoms leave the corresponding square blank. If present indicate severity.

1. Mild-1: Noticeable but not troublesome.
2. Moderate-2: Interferes with normal activity.
3. Severe-3: Temporarily incapacitating.

Lifestyle Impact:

1. If the listed phrase applies to you that day enter an [x].

Life Events: If you experienced one of these events that day enter an [x].

1. Experiences: for positive (happy) or negative (sad or disappointing) experiences unrelated to your symptoms specify the nature of the events on the reverse side of this form.
2. Social Activities: imply events such as a special dinner, show or party etc, involving family or friends.
3. Vigorous Exercise: implies participation in a sporting event or exercise programme lasting more than 30 minutes.
4. Medication: In the bottom 3 rows list medications if any and indicate days when taken by entering an [x].