Appendix 1.

Daily Urinary Pad Log

Daily Urinary Pad Log
Case #: __________	Initials: ___________	Surgery Date: ____/____/_____
Please Fax at Highlighted Times. Thank You
Before your surgery, did you wear urinary pads for incontinence problems? □Yes, # daily? ____ □ No

Week 1
				Check Type of Urinary Pad Used
Day	Date	# of Pads Used	How soaked are your pads? (0-100%)	L Light (Thin liner)	M Medium (Standard pad)	H Heavy (Disposable brief)	Comments (Use additional sheets as needed.)
0							Catheter Removed
1
2
3
4
5
6
7							Please Fax to
Are you currently taking medication for incontinence? □ Yes, Name:______________ Date Started: _________ □ No