Fill this in before your appointment and take it with you. The more specific you are, the easier it is for your doctor to see the pattern. Many symptoms have more than one cause, so you are gathering information, not reaching a conclusion.
| Name | |
| Date of appointment | |
| Date of last period (first day) |
| 1. | |
| 2. | |
| 3. |
What I would like from this appointment (for example a test, a referral or an explanation):
Tip: count over two or three cycles if you can.
| How many days does bleeding last (including spotting)? | |
| Cycle length (first day of one period to the first day of the next) | |
| How often do I change a pad, tampon or period underwear, or empty a cup, on my heaviest days? Every 1 to 2 hours? | |
| Do I double up (for example tampon and pad together)? Do I leak or flood onto clothes or bedding? | |
| Do I wake in the night to change? How many times? | |
| Clots: how big (larger than about 2.5 cm?), how many, which days? | |
| Bleeding between periods, after sex, or after my periods stopped for a year? | |
| Pain: where, how bad (0 to 10), which days, do painkillers help? | |
| Has anything changed (after a baby, contraception, recent months)? |
For each symptom you have, note how often, how long, how bad it is (0 to 10), when it started and what makes it better or worse. Add your own at the bottom.
| Symptom | How often | How long | Score /10 | Started / better or worse |
|---|---|---|---|---|
| Tiredness (every day, even after a full night's sleep?) | ||||
| Hair loss (daily when brushing or washing? how much?) | ||||
| Headaches (days per month, time of day, with periods?) | ||||
| Muscle cramps (where? at night? how often?) | ||||
| Dizziness or fainting (when standing up?) | ||||
| Palpitations or racing heart (when, how long?) | ||||
| Breathlessness (stairs, short walk, or at rest?) | ||||
| Brain fog, mood, anxiety, sleep | ||||
| Other: feeling cold, pale, brittle nails, restless legs, mouth sores, cravings | ||||
| Gut: bowel changes, blood or black stools | ||||
Red flags: do not wait for a routine appointment if you have severe bleeding, chest pain, fainting, breathlessness at rest or any symptom that feels urgent. Call 111, or 999 in an emergency.
| Blood loss in the past (childbirth, surgery, injury) and when | |
| Diet: how often I eat meat, fish, beans or leafy greens. Tea or coffee with meals? | |
| Medicines and supplements (including painkillers, antacids, iron) | |
| Do I donate blood? How often? | |
| Family history (anaemia, heavy periods, thyroid, bowel conditions) | |
| Previous blood results (dates, numbers and the lab ranges) |
Whether a test is right for you is your doctor's decision. You can ask about it, and ask why it is or is not offered.
Write down what was said and agreed before you leave the room. Ask for it to be repeated if you need to.
| What the doctor thinks may be causing my symptoms | |
| Tests or checks agreed (and when I will get results) | |
| Treatment or advice given | |
| Referral agreed (to whom, and when) | |
| What I should do if things get worse | |
| Follow-up date | |
| Things I forgot to ask |
BioHer provides educational information only. It is not medical advice, diagnosis or treatment, and it does not replace your GP or other healthcare professional. If symptoms feel urgent or severe, call 111 for urgent advice, or 999 in an emergency. Full guide: bioher.co.uk/blog-gp-appointment.html