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.
Figure 1: Bladder Record
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|
Posted October 2006
Last Reviewed October 2011
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