Home > Voiding Log (Bladder Record)
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.
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).
Urinated in toilet
Had a small incontinence episode
Had a large incontinence episode
Reason for incontinence episode
Type/amount of liquid intake
Number of times urine leaked today:
Number of absorbent pads used today:
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).
Current as ofMarch 20, 2018
Author: Healthwise StaffMedical Review: E. Gregory Thompson, MD - Internal MedicineAdam Husney, MD - Family MedicineAvery L. Seifert, MD, FACS - Urology
Current as of:
March 20, 2018
Medical Review:E. Gregory Thompson, MD - Internal Medicine & Adam Husney, MD - Family Medicine & Avery L. Seifert, MD, FACS - Urology
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