Supporting kids with chronic bowel and bladder conditions
National Help Line: 1300 885 209
Alternatively 03 9739 5548
CLICK HERE FOR THE GLOSSARY IF YOU DON'T UNDERSTAND THE QUESTIONS
Trial Phase Before Stims During Stims After Stims
TREATMENTS
Have you had any treatments today? YES NO If yes...What type of treatment did you have? . Medications Electrical Stimulation Other
If medications please explain
What time did you have the treatment . Between 7am - 9am Between 9am - lunchtime Between 12pm - 4pm Between 4pm - 6pm Between 6pm - 10pm
When did you go to the toilet next after treatment None During treatment Straight after treatment (up to 30 minutes) 1 to 2 hours after treatment 2-4 hours after treatment I didn't go to the toilet after treatment
Do you have a stoma . Appendicostomy (Chait) Did you have a washout . YES NO
What did you use in the washout . Saline Licorice root Colonlytely Other... please tell us what it was Other:
How much did you use for your washout . Less than 100 mls 100mls 200mls 300mls 400mls 500mls 1000mls
What time did you have it? . Before 7am Between 7am - 9am Between 9am-12am Between 12pm-4pm Between 4-7pm After 7pm
Toilet Stops
1st Poo Time 0 7am 8am 9am 10am 11am 12 lunchtime 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10 - 12pm 12am - 6am How . Planned Spontaneous Accident How much . 1/4 cup 1/2 cup 3/4 cup 1 cup 1 and half cup 2 cups more than 2 cups Type . 1 2 3 4 5 6 7
2nd Poo Time 0 7am 8am 9am 10am 11am 12 lunchtime 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10 - 12pm 12am - 6am How . Planned Spontaneous Accident How much . 1/4 cup 1/2 cup 3/4 cup 1 cup 1 and half cup 2 cups more than 2 cups Type . 1 2 3 4 5 6 7
3rd Poo Time 0 7am 8am 9am 10am 11am 12 lunchtime 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10 - 12pm 12am - 6am How . Planned Spontaneous Accident How much . 1/4 cup 1/2 cup 3/4 cup 1 cup 1 and half cup 2 cups more than 2 cups Type . 1 2 3 4 5 6 7
4th Poo Time 0 7am 8am 9am 10am 11am 12 lunchtime 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10 - 12pm 12am - 6am How . Planned Spontaneous Accident How much . 1/4 cup 1/2 cup 3/4 cup 1 cup 1 and half cup 2 cups more than 2 cups Type . 1 2 3 4 5 6 7
5th Poo Time 0 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10 - 12pm 12am - 6am How . Planned Spontaneous Accident How much . 1/4 cup 1/2 cup 3/4 cup 1 cup 1 and half cup 2 cups more than 2 cups Type . 1 2 3 4 5 6 7
DID YOU HAVE ANY ACCIDENTS TODAY YES NO
Tummy pain
Have you had any tummy pains today YES NO Indicate what your pain score was 0 - no pain 1-3 mild pain 3-5 moderate pain 7-9 severe pain 10 worst pain possible
Please check your answers before clicking SUBMIT
PCAA is a member of the following organizations
Members of Continence Foundation of Australia
Chronic Illness Alliance
Questions or problems regarding this web site should be directed to mail@pcaa.org.au Copyright © 2007 Paediatric Continence Association of Australia Inc. All rights reserved. Last modified: 08/13/09.
