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Baseline Week

This data is what your final week, after treatment will be compared to.

Question Title

* 1. Type in your name.

Question Title

* 2. What date did you start recording? 

Date

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* 3. Record your leaks

  Urge Leaks
(leaks after sudden urge to pee) 		Near Misses
(sudden urge, but made it to toilet in time) 		Stress Leaks
(leaks from cough, sneeze, movement)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7

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* 4. Record your bathroom visits and pad use

  Daytime Bathroom Visits Nighttime Bathroom Visits Pads Worn
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7

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* 5. Record any Notes you took (e.g. activity level, situation around accidents)

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 100% of survey complete.

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