Colostomy Gas Release Log Form
Log and track colostomy gas-release events for clinical monitoring and review.
Date and Time of Event
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Event
*
Was a pouch change needed?
*
Yes
No
Was a skin issue noticed?
*
Yes
No
Odor Level
*
Please Select
None
Mild
Moderate
Strong
Estimated Gas Release Intensity
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Associated Symptoms
Abdominal discomfort
Bloating
Nausea
No symptoms
Other
Event Context
*
During eating
After eating
At rest
Overnight
Additional Notes
Was this event unusual compared to your typical experience?
Yes
No
Submit Log
Should be Empty: