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Voiding Log (Bladder Record) - Forrest Health
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    Voiding Log (Bladder Record)

    Topic Overview

    Complete one of these records each day for several days, then take the completed records to your doctor. This information will help you and your doctor see how often you leak urine and what seems to cause the leakage.

    Name:

    Date:

    Instructions: Place a check mark 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 or water) and estimate the amount (for example, 1 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 a.m.–noon






    Noon–2 p.m.






    2–4 p.m.






    4–6 p.m.






    6–8 p.m.






    8–10 p.m.






    10 p.m.–midnight






    Overnight






    Number of times urine leaked today:

    Number of absorbent pads used today:

    Comments:

    Source: Fantl JA, et al. (1996). Urinary Incontinence in Adults: Acute and Chronic Management: 1996 Update. AHCPR Clinical Practice Guidelines, No. 2. Rockville, MD: Agency for Health Care Policy and Research (AHCPR).

    Credits

    Current as ofMarch 20, 2018

    Author: Healthwise Staff
    Medical Review: E. Gregory Thompson, MD - Internal Medicine
    Adam Husney, MD - Family Medicine
    Avery L. Seifert, MD, FACS - Urology