Sample Bladder Record

NAME___________________________ DATE________________________________

INSTRUCTIONS: Please record times you urinate in the toilet, times an incontinence episode occurred. Record the activity during 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


Activity during leakage Fluid ounces of liquid intake
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.                

Number of pads used today:___________ Number of episodes_____________



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