InterStim Therapy. symptom diary
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1 InterStim Therapy symptom diary
2 Symptom DIARY Begin date: End date: Baseline Test assessment Follow-up visit 2
3 Your doctor and Medtronic, maker of InterStim Therapy, know that finding the right treatment option requires a bit of patience, and we re glad you haven t given up hope. Together, you and your doctor can work to find a solution for you: the treatment that reduces, or perhaps even eliminates, your bowel incontinence symptoms. In order to help your doctor better understand your symptoms, it s important that you keep a detailed log of all bowel episodes for several consecutive days as instructed by your doctor. The information you record here will help your doctor determine the best treatment for you. Please answer all of the questions in the Symptom Diary. HOW TO EFFECTIVELY USE THIS Symptom DIARY The Symptom Diary allows you to keep track of the number of bowel episodes you experience during a set timeframe. It will help reveal the extent of your condition and is an important step in regaining your bowel control. Begin this diary when instructed by your doctor. Record only one episode per column. 3
4 Recording Your Episodes Beginning at the top of each column, record the date and time of day each episode occurred. Then answer each of the questions concerning your bowel episode. An episode is considered either of the following: a. Defecation: bowel movement in the toilet (continent event). b. Fecal incontinence: accident or leaking involving stool. Use these Definitions of Incontinence related to the amount of incontinence: Stain on undergarment, pad, clothing, or skin. An episode that didn t require an immediate change of undergarment, pad, or clothing. An episode that required an immediate change of undergarment, pad, or clothing. Answer All Questions Choose only one answer per question. If you have a day without any accidents or episodes, fill in the date and check the box, Episodes Today. If you fill up this diary, continue recording episodes using another diary. If you have any questions concerning this diary, please consult your doctor. Please take the completed diary to your next doctor visit. 4
5 Stool Descriptions Use these numbered drawings to indicate in the diary what type of event occurred. 1 pellets 5 mushy 2 formed and hard 6 loose 3 formed and soft 7 watery 4 semi-formed 5
6 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 6
7 Episodes Today Episodes Today ne ne 7
8 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 8
9 Episodes Today Episodes Today ne ne 9
10 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 10
11 Episodes Today Episodes Today ne ne 11
12 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 12
13 Episodes Today Episodes Today ne ne 13
14 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 14
15 Episodes Today Episodes Today ne ne 15
16 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 16
17 Episodes Today Episodes Today ne ne 17
18 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 18
19 Episodes Today Episodes Today ne ne 19
20 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 20
21 Episodes Today Episodes Today ne ne 21
22 Daily Diary Record ONE EPISODE per column, even if there is more than one per day. Choose the ONE best answer for each question. Episodes Today Episodes Today ne ne 22
23 Episodes Today Episodes Today ne ne 23
24 Important Safety Information About InterStim Therapy InterStim Therapy for Bowel Control treats chronic fecal incontinence (an accident or leaking involving stool). It should be used after you have tried other treatments such as medications and dietary modifications and they have not worked, or if you are not a candidate for them. You should have a successful trial assessment before receiving InterStim Therapy. You cannot have diathermy (deep heat treatment from electromagnetic energy) if you have an InterStim device. Safety and effectiveness have not been established for pregnancy and delivery; patients under the age of 18; or for patients with progressive, systemic neurological diseases. In addition to risks related to surgery, complications can include pain at the implant sites, new pain, infection, lead (thin wire) movement/migration, device problems, interactions with certain other devices or diagnostic equipment such as MRI, undesirable changes in urinary or bowel function, and uncomfortable stimulation (sometimes described as a jolting or shocking feeling). This therapy is not for everyone. Please consult your physician to decide whether InterStim Therapy is right for you. A prescription is required. For further information, please call Medtronic at and/or consult Medtronic s website at www. medtronic.com. USA Rx Only. Rev Medtronic Neuromodulation 710 Medtronic Parkway Minneapolis, MN USA Tel Toll-free UC EN NI Medtronic, Inc. Printed in USA.
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