INSTRUCTIONS FOR SPLINT DIARY: Please darken the circle beside the number of hours you used your splint each day while you were up and around and while you were in bed. Record bedtime hours on the day that you went to sleep, not on the day that you woke up. For example, if you wore your splint to bed on Monday night, slept for 8 hours and took it out on Tuesday morning, you would darken the circle indicating 6 + hours used while asleep on Monday.

Table 14.1 Assessing Patient Compliance With RCT Protocol:
SPLINT USE DIARY
UNIVERSITY OF WASHINGTON
Week: ____
Day/Date # Hours Splint Used While Awake # Hours Splint Used While Asleep Pain Medications Taken Today Problems/ Comments
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 
___/___ 0 hours
1-2 hours 3-5 hours
6 + hours

0 hours
1-2 hours
3-5 hours
6 + hours

None
Non-narcotic
Narcotic		 

USEFUL TIPS FOR COMPLETING YOUR SPLINT DIARY:

  1. Record hours of splint use DAILY, once before bedtime and once after awakening.
  2. Place the diary in a highly visible and convenient location. The bathroom mirror, refrigerator door, or bedside table are good locations.
  3. Make sure to keep a pen or pencil with the diary.
  4. Mail the diary in the attached postage guaranteed Business Reply envelope as soon as you complete it.
  5. If you have any questions or problems, call the Study Coordinator at 543-5912.