PeriOne-page appointment summary
Put your top concerns, period changes, medicines and questions on one page. Type here and print, or print it blank and write by hand.
This tool runs in your browser. Nothing you choose or type is saved, sent or tracked. Print it, or choose “Save as PDF” in the print dialog, before you close the page.
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Appointment summary
Bring this page and your diary or report. Date of appointment: ____________
Main reason for this appointment
Top concerns
| Symptom | Since when | How often | Effect on daily life |
|---|---|---|---|
Periods: date of last period and any changes
Medicines, HRT, supplements and contraception
Other health conditions or family history to mention
My questions
What I’d like from today
Printable from peridaily.com. For your own records; general information, not medical advice.
Not sure what to include? Read how to prepare for a perimenopause appointment.
From paper to Peri
If you track in Peri, Premium creates a PDF report from your logs to bring alongside this page. See what it contains.
