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keeping a bladder record

by Diane K. Newman, DNP, FAAN, BCB-PMD

Keeping a bladder record may be very useful when you are making changes to behaviors and lifestyle habits to control urinary incontinence symptoms. Here's a form you can use to make it easier.

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Figure 1: Bladder Record

Name____________________


Date_____________________


Instructions for Bladder Record

Column 1 - Place a check next to the time you urinated in the toilet.


Column 2 - Place a check next to the time you have an accident, large or small.


Column 3 - Place a check next to the time you change your WET PADS.


Column 4 - Note a reason why you may have had an accident, like sneezing, coughing, lifting something heavy, "couldn't make it to the bathroom," etc.


Column 5 - Make a check for every 8 oz or 1 glass of fluid you drink and indicate if it contains caffeine.

  Column 1 Column 2 Column 3 Column 4 Column 5
Time Interval Urinated in toilet Had an accident Changed wet pad Reason for accident The fluid I drank
6-8 AM          
8-10 AM          
10-12 Noon          
12-2 PM          
2-4 PM          
4-6 PM          
6-8 PM          
8-10 PM          
10-12 PM          
Overnight          

Posted October 2006
Last Reviewed October 2011
 

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