1. Rate your current pain level (1 = Mild, 10 = Severe):

2. Which day of your menstrual cycle are you on?

3. What type of pain are you experiencing?

Sharp/Stabbing Dull/Aching Cramping

4. How frequently does the pain occur?

Constant Intermittent Occasional

5. Are you experiencing additional symptoms? (Check all that apply):

Nausea Fatigue Back Pain Bloating

6. How sensitive is your skin to touch in the affected area?

Very Sensitive Moderately Sensitive Not Sensitive

7. Do you want to use the heat pad?

Yes No

8. If using the heat pad, select your preferred heat level:

Low Medium High