Sample Bladder Record

Sample Bladder Record

DATE____________

INSTRUCTIONS:

Please record times you urinate in the toilet,
times an incontinence episode occurred.
Record the activity associated with the incontinence.
Record the volume and type (in ounces) of liquid consumed, (1 cup equals 8 ounces).

Time interval	# Times toilet urination	# Incidents of incontinence	Amount of leakage	Degree of urgency 0-1-2	Activity during leakage	Fluid ounces of liquid intake
Time interval	# Times toilet urination	# Incidents of incontinence	Amount of leakage	Degree of urgency 0-1-2	Activity during leakage	Water	Soda	Coffee/Tea
6-8 a.m.
8-10 a.m.
10- noon
Noon-2 p.m.
2-4 p.m.
4-6 p.m.
6-8 p.m.
8-10 p.m.
10-midnight
Overnight

Number of pads used today:___________ Number of episodes_____________

Comments:________________________________________________________________

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