SCORE BOARD© TREATMENT CENTER FORM

R = Required Information

Patients Name:	R
Email:	R
Phone:	R
Week of:	R

For each day of the week indicate weather the enuretic was wet or dry. If wet, please select in the number of times and the size of the spots. If dry for the day, please select Dry.

SUN Wet How many times? 1 time 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry MON Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry TUE Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry WED Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry THU Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry FRI Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry SAT Wet How many times? 1 times 2 times 3 times 4 times 5 times 6 times 7 times 8 times 9 times 10 times Spot size if wet small spot medium spot large spot Dry

DO NOT EAT OR DRINK THE FOLLOWING. DO NOT VARY FROM THIS DIET FOR THE FIRST WEEK… THEN REFER TO THE DIET IN THE KIT!

Please check the foods below where the child has cheated.

SUN Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

MON Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

TUE Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

WED Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

THU Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

FRI Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

SAT Milk, Yogart Other Dairy Products Coffee, Tea, Ice Tea Soft Drinks, Sodas Kool-Aid, Colored Drinks Fast Foods: Wendys, Pizza, McDonalds, etc. Chocolate Sugar, (presweetened cereal cake) Cookies Chips, Spicy Foods Preservatives, MSG

PLEASE, understand that these are temporary food corrections. You cannot have milk or milk products of any kind. DO NOT drink or cook with milk...Suggestions use: Silk Milk or Soy Milk…Eggs are not dairy so you may eat eggs. Buy non-dairy products in the larger grocery chains and health food stores and on the web. Sweeten with Splenda. Use organic and natural foods and drinks.

OH NO! They have taken away all my favorite things. I need my "junk food". Not for long, when you have been dry for (3) three weeks, you can slowly add these foods to your diet. Which is important, a few weeks of restraining from your favorite "diet" or a "dry bed"? Think about an over-night trip without the worry of wetting the bed.

Please use this area for any additional comments or details needed.

Name of Parent filling out this form

Idea - you may want to print this form after you have completed it and before submitting so that you have a copy for yourself

All information is held strictly confidential.
Copyright 2008 All rights reserved
The Hargitt House Foundation
Houston, Texas (281) 298-2888
email: info@hargitthousefoundation.com