Prism Calendar, Courtesy of Dr. Robert Reid.
Baseline weight on Day 1:___________ Lbs. or Kg. (circle 1).
Instructions for Completing this Calendar:
- 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.
- Each Morning: Take weight after emptying bladder and before breakfast. Record Weight Change from baseline.
- Each Evening: At about the same time complete the column for that day as described below.
- 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.
- Mild-1: Noticeable but not troublesome.
- Moderate-2: Interferes with normal activity.
- Severe-3: Temporarily incapacitating.
- If the listed phrase applies to you that day enter an [x].
If you experienced one of these events that day enter an [x].
- 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.
- Social Activities: imply events such as a special dinner, show or party etc, involving family or friends.
- Vigorous Exercise: implies participation in a sporting event or exercise programme lasting more than 30 minutes.
- Medication: In the bottom 3 rows list medications if any and indicate days when taken by entering an [x].