Sample Bladder Record

NAME: ____________________________________________

DATE: ____________________________________________

INSTRUCTIONS: Place a check in the appropriate column next to
the time you urinated in the toilet or when an incontinence episode occurred.
Note the reason for the incontinence and describe your liquid intake (for
example, coffee, water) and estimate the amount (for example, one cup).

Time interval

Urinated in toilet

Had a small incontinence episode

Had a large incontinence episode

Reason for incontinence episode


Type/amount of liquid intake

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

____________

________________

________________

________________

____________

No. of pads used today:

No. of episodes:

Comments:
_______________________________________



About Incontinence

Avatar Written by Agency for Health Care Policy and Research

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