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Teen Period Symptoms Doctor Visit Sheet

A simple visit sheet for teens to track period dates, heavy bleeding, pain, missed school, medicine use, questions, and privacy notes before a doctor visit.

Use this sheet before a doctor visit about your period. You do not need perfect notes. Bring what you know.

This is not a diagnosis. It is a way to help you explain what has been happening.

1. Basic visit notes

Question Your notes Visit date Main reason for the visit First day of your last period How long bleeding lasted Usual cycle length, if known Any chance of pregnancy Current medicine or birth control What you most want help with

2. Recent period log

Fill in what you remember.

Period Start date End date Heavy days Worst pain 0 to 10 Missed school or plans : 1 2 3 4 5 6

If your first period was recent, your cycle may not be regular yet. ACOG says menstrual history can help clinicians understand adolescent health.

3. Bleeding notes

Use plain words.

Check Your notes Pads, tampons, cups, or period underwear used each day Times you leaked through clothes or bedding Clots, if any Bleeding longer than 7 days Feeling dizzy, weak, or faint Nosebleeds, easy bruising, or bleeding after dental work

ACOG says heavy bleeding in teens may need evaluation. If you feel weak, faint, or very unwell, ask for help now.

4. Pain and symptom notes

Symptom When it happens How bad 0 to 10 What helps : Cramps Back pain Headache Nausea Diarrhea Mood changes Tiredness

Write down medicine too.

Medicine or comfort step Dose, if known Helped? yes / no / not sure yes / no / not sure yes / no / not sure

5. School and life impact

Question Your notes Missed school days Missed sports, work, or plans Had to leave class Needed extra bathroom trips Could not sleep Felt worried about leaks

These notes help the doctor understand how much your period affects your day.

6. Questions to ask

Pick three.

Is my bleeding amount okay? Is my pain level okay? What can I try for cramps? Should I be checked for anemia? Should I be checked for a bleeding disorder? Are my cycle gaps normal for my age? What should make me call the clinic? What can stay private in this visit?

Write your own questions.

Question Answer

7. Privacy notes

You can ask:

text Can I talk with the doctor alone for part of the visit?

Can you explain what stays private and what you have to share?

Can I choose what period app notes or screenshots to show?

Rules can vary. Ask before you share anything that feels sensitive.

8. What to bring

This sheet. Your period app or paper log. A list of medicines. Photos of products or clots only if you choose to show them. Questions you wrote down. A support person, if you want one.

Floriva note

Floriva can help you keep dates and notes in one place. Before a visit, copy only the facts you want to share.