Interstitial Cystitis Diary: Pain And Symptom Tracker, Guided Record Book with daily Discomfort Assessment, Mood, Sleep, Activity, Medication Logbook, ... Bladder Syndrome IC/BPS Management Gifts

Triggers, Symptoms and Pain overall

Triggers - check one of the available triggers or add your own in the lined space left for you

Symptoms - check one of the pre-listed symptoms or add to the lined spaces left available for you

Pain location - mark on the image (both front and back are available)

Pain Overall - enter a number ranking, and check one of the pre-listed available or enter your own on the lines available

Issue Tracker

Pain Tracker - when pain or discomfort comes sporadically during the day you can enter the symptom here (along with the trigger if identified), when the symptom occurred, and circle a number to indicate the severity.

Daily Assessments, Activities

Urinary Frequency - circle applicable arrow to indicate 'Increased, Same, Decreased' for morning, afternoon, evening and at night.

Daily Assessment - circle applicable arrow to indicate 'Increased, Same, Decreased' for Pain, Stress, Energy, Activity Level, Sleep Quality and General Mood.

Activities - select from prelisted options and enter time as desired.

Sleep - enter quality, hours at night and daytime hours.

* See sample completed page.

Meals & Sncaks and Medications

Meals & Snacks, when eaten and a note if desired. Checkboxes available to indicate if the meal included spices, dairy, gluten, sugar or fats.

Hydration

Medications - checkboxes to indicate 'Usual daily medications' and/or 'Usual daily suppliments'. List additional medications/reason, time, dose and whether it helped.

Example of completed page

Note marks on image to indicate urinary pain and headache.

Discomfort on way home from work was enough to cause stop en route to use facilities. Effect severity was a '5'.

Example of completed page

Today's date - day is rated at a 6 on a scale of 1-10

Pain and stress were increased, energy level and general mood decreased while activity level and sleep quality remained consistent.

Urinary frequency in the morning was the same, while afternoon, evening and overnight frequency increased.

Sleep was broken with 5 hours at night and no naps.

Hydration - note less liquids taken in - attempt to lessen getting up at night.

Personal Information and healthcare Team

Introductory page has space for personal info including allergies and medical alerts.

Enter doctor and contact info.

Enter pharmacy and contact info.

Enter insurance information.

Medications and Changes

Page for current medications / supplements along with reason and refill due date.

Page for CHANGES to medications and supplements with reason for the change, new dose, and date effective.

Medications and Foods/Drinks to avoid

Avoid.

Medical Appointments, Walking and Exercise logs

Upcoming medical appointments - with whom? for what reason, and date

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