Natural Therapy Effectiveness Assessment Form

Professional tool for systematically evaluating the effectiveness of different natural therapies

periodhub.health | Women's Health Management Tools

📋 Instructions for Use

I. Basic Information Section

User Basic Information

Name/User ID
Age
Main Assessment Symptom Start Time

Main Assessment Symptoms (Multiple selections allowed)

☐ Menstrual pain
☐ Premenstrual mood swings
☐ Bloating
☐ Fatigue/lack of energy
☐ Insomnia/poor sleep quality
☐ Headache
☐ Other: _____________

Current Assessment Cycle Information

Assessment Start Date ______ Year ____Month ____Day
Assessment End Date ______ Year ____Month ____Day
Cycles Covered ______ Complete menstrual cycles

Main Goals and Expectations

What specific effects do you hope to achieve through this assessment and the natural therapies you try?

For example: Reduce menstrual pain intensity by 50%, reduce pain medication use, more stable mood, etc.

II. Therapy Record Section

Please record all natural therapies you try during this assessment cycle. You can try multiple therapies and track their effects simultaneously.

# Therapy Name/Description Type Frequency Duration per Session Start Date End Date
Example 30-minute brisk walk daily Exercise Daily 30 minutes 2024-01-01 2024-01-31
1      
2      
3      
4      
5      

🌿 Common Natural Therapy Types

  • Herbs/Supplements
  • Dietary adjustments
  • Exercise
  • Meditation/Relaxation
  • Physical therapy
  • Aromatherapy
  • Acupuncture/Massage
  • Others

📝 Recording Examples

  • Angelica granules, three times daily
  • Low-gluten diet
  • Yoga, 3 times per week
  • Acupoint massage: Hegu + Zusanli
  • Lavender essential oil
  • Abdominal heat therapy
  • Mindfulness meditation

III. Daily Tracking Log

Please record daily or when symptoms occur during the assessment cycle. Use 0-10 scale to assess intensity and levels.

0
No symptoms
Lowest
2-3
Mild
Slight discomfort
4-6
Moderate
Obvious impact
7-8
Severe
Significant impact
9-10
Extreme
Highest/Strongest
Date Menstrual Cycle Phase Main Symptom Intensity(0-10) Symptom Duration Mood Level Energy Level Therapies Used Today Immediate Effect Feeling
Example
01-15		 Menstrual Day 2 Pain:7
Bloating:5
Fatigue:6		 4 hours 4 3 Therapy 1,3
Heat therapy 30min		 Pain slightly relieved
No change in bloating
Mood improved
        
        
        
        
        
        
        
        
        
        

IV. Cycle Summary and Assessment Section

After completing this assessment cycle, please review your records and conduct a summary assessment.

Overall Symptom Change Review

Symptom Frequency Change ☐ Significantly decreased ☐ Slightly decreased ☐ No change ☐ Slightly increased ☐ Significantly increased
Symptom Intensity Change ☐ Significantly reduced ☐ Slightly reduced ☐ No change ☐ Slightly increased ☐ Significantly increased
Symptom Duration Change ☐ Significantly shortened ☐ Slightly shortened ☐ No change ☐ Slightly extended ☐ Significantly extended

Therapy Effectiveness Assessment

Overall Effectiveness Score ________ / 10 points (0=completely ineffective, 10=very effective)
Most Helpful Therapy
Discomfort or Side Effects

Follow-up Decisions

Will you continue using these natural therapies?
☐ Yes, continue all ☐ Yes, continue some ☐ No, stop all therapies ☐ Need adjustments
Please specify your plan:
Are there other therapies you need to try?

⚠️ Important Notice

This assessment form is a tool to help you self-observe and evaluate, and cannot replace professional medical diagnosis.

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