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

Number of pads used today:___________ Number of episodes_____________

Comments:________________________________________________________________

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