Menstrual Pain Symptom Tracking Form

📋 Instructions for Use

Fill out the form promptly when symptoms occur to ensure accuracy
If you try multiple relief methods, evaluate each one separately
Continuous recording over several menstrual cycles can help you discover patterns and the most effective relief strategies
We recommend printing multiple copies or copying the table content to an electronic document

Pain Intensity Rating Scale

1-2

Mild Pain
No impact on daily activities

3-4

Light Pain
Slight discomfort

5-6

Moderate Pain
Affects work efficiency

7-8

Severe Pain
Requires rest

9-10

Extreme Pain
Unbearable

Symptom Tracking Record

Date & Time	Symptom Description	Pain Level (1-10)	Possible Triggers	Relief Methods Used	Method Effectiveness	Notes
Example: 2024-01-15 2:30 PM	Lower abdominal cramps Lower back pain Mild headache	6	High stress Lack of sleep Cold drinks	Heat therapy 30min Ginger tea Light yoga	Moderate relief	Workday Anxious mood

Common Symptoms Reference

🔸 Pain Symptoms

☐ Abdominal cramps

☐ Lower back pain

☐ Headache

☐ Inner thigh pain

🔸 Other Symptoms

☐ Nausea/vomiting

☐ Fatigue

☐ Mood changes

☐ Bloating

Trigger Factors Reference

🔸 Lifestyle

☐ Stress

☐ Lack of sleep

☐ Cold exposure

☐ Specific activities

🔸 Dietary Factors

☐ Cold drinks

☐ Spicy food

☐ Caffeine

☐ High sugar foods

🔸 Other Factors

☐ Emotional changes

☐ Environmental changes

☐ Medication effects

☐ No obvious triggers

Relief Methods Reference

🔸 Physical Therapy

☐ Heat therapy (abdomen/back)

☐ Light exercise (yoga, walking)

☐ Acupressure

☐ Massage

🔸 Other Methods

☐ Herbal tea/drinks (ginger tea, etc.)

☐ Meditation/deep breathing

☐ Rest/sleep

☐ Pain medication (specify name)

Effectiveness Assessment Criteria

Assessment Level	Description
No Effect	No pain relief, no symptom improvement
Slight Relief	Pain slightly reduced, but significant discomfort remains
Moderate Relief	Pain significantly reduced, can perform some daily activities
Significant Relief	Pain mostly or completely gone, return to normal activities

⚠️ Important Notice

This form is a personal symptom tracking tool and cannot replace professional medical diagnosis.

If your menstrual pain symptoms are severe, persistent, or accompanied by the following conditions, please consult a doctor promptly:

Pain level reaches 8 or above and lasts for extended periods
Accompanied by fever, abnormal bleeding, or discharge
Sudden changes in pain patterns
Complete ineffectiveness of usual relief methods