Can this template replace a medical record?

No. It is your own worksheet. Your clinic, lab, pharmacy, and insurer may each have their own records.

Can I use this with an app?

Yes. You can print it, use it in a notebook, or copy it into a private app. Check where the data is stored before you add sensitive notes.

What if I do not know all the dates?

Write what you know. Add question marks when you are unsure. A partly filled record can still help.

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Personal Cycle Health Record Template

A printable personal cycle health record for dates, symptoms, flow, medicines, allergies, tests, care contacts, privacy notes, and visit summaries.

A cycle health record is a place for the facts you may need later.

It can be paper. It can be a file. It can be an app you trust. The point is simple: keep useful notes together before a visit, test, refill, or new symptom.

This template does not tell you what is wrong. It does not tell you what care to choose. It helps you bring clear notes to care.

Quick record card

Keep this page near the front.

Field Your notes Name used at care visits Date of birth Main clinic or care team Pharmacy Emergency contact, if you want one Last period start date Usual cycle length Usual period length Current birth control or hormone medicine Health notes you want clinicians to know Notes you do not want in shared files

If you need a daily symptom page, use the period symptom tracker printable with this record.

Cycle dates

Use one row per cycle. A rough date is better than a blank.

Cycle Period start Period end Cycle length Flow days Spotting days Main symptoms Notes : : : 1 2 3 4 5 6

For a longer daily log, start with the cycle tracking starter template.

Symptom snapshot

List symptoms that come back. Keep the words plain.

Symptom When it tends to happen How bad, 0 to 10 What helps, if anything What makes it worse Ask about this? : Cramps Pelvic pain Heavy bleeding Spotting Headache or migraine Mood change Sleep change Digestive change Other

Do not use this table to name a cause. Use it to show a pattern.

Medicines and supplements to mention

Write what you take now. Include birth control, hormones, pain medicine, vitamins, herbs, and over the counter medicine.

Name Dose, if known How often Why you take it Started Stopped Notes for visit

Do not start, stop, or change medicine because of this worksheet. Ask a clinician or pharmacist.

Allergies and reactions

Bring this to visits and pharmacy calls.

Medicine, food, product, or material What happened When it happened How severe Who knows about it?

If you are not sure whether something was an allergy, write "reaction" and describe it.

Tests, images, and procedures

Keep dates and locations. You do not need to copy full reports here.

Date Test or procedure Where it was done Why it was done Result summary Where the record lives

Examples may include blood work, urine tests, Pap tests, STI tests, ultrasound, MRI, surgery, or biopsy.

Care contacts

Use the names that help you find the right record later.

Role Name Clinic or company Phone or portal What they handle Primary care OB GYN or clinician Pharmacy Lab Insurance plan Other

You can also use Floriva for gynecologist prep if you want to turn cycle notes into a visit summary.

Questions for your next visit

Write the questions before the visit. Put the most important one first.

Priority Question Why you are asking Answer or next step : 1 2 3 4 5

If bleeding is the main concern, the abnormal bleeding diary and heavy period visit prep checklist can help you bring more detail.

One page visit summary

Fill this out before a visit. Keep it short.

Field Your notes Main reason for the visit When it started What changed Worst day or pattern Top symptoms Current medicines and supplements Allergies or reactions Recent tests or visits What you want help deciding What you want kept private

Short notes help when the visit feels rushed.

What to keep out of shared notes

Some notes belong in your private record first. Before you copy them into a portal, app, email, family calendar, or shared note, ask:

Does my clinician need this exact detail? Could a shorter note work? Does this name another person? Does this include sex, pregnancy, location, travel, money, or legal concerns? Could this show on a shared screen? Could this save to cloud photos, downloads, email, or texts?

To see where notes go, use the period app data map worksheet.

To save less data, read the period tracker data minimization guide.

For visit notes, read period tracking data for doctor appointments.

Private copy checklist

Mark what you have saved.

A paper copy at home. A copy you can bring to a visit. A copy that does not sync to a shared account. A list of records you still need. A plan for old screenshots or downloads. A note about what not to share.

This record should serve you. Keep the parts that help. Skip the parts that do not.