This Chart is a record of your voiding (urinating) and leakage (incontinence) of urine. Please follow the instructions below prior to your next visit to our office.

Instructions: Choose 3 days, not necessarily consecutive days. Keep the record when you can conveniently measure trips to the bathroom. Begin your record with the first voiding upon arising in the morning.

1. Record times of all intake of liquid and voids.

2. Measure all intake in ounces (1 cup = 8 ounces) or in ccs.

3. Measure all trips to the bathroom in ccs. For example, the top number on the urine collection container we have given you is 1000 cc.

Day 1                                                               Day 2

Day 3

If you are also having problems with incontinence, fill out 2^nd diary below regarding your leakage.

1. Describe the activity you were performing at the time of leakage.  If you were not actively doing anything, record whether you were sitting, standing or lying down.
2. Estimate the amount of leakage according to the following scale:

1 = damp, a few drops only

2 = wet underwear or pad

3 = soaked or emptied bladder

1. If the urge to urinate accompanied (or preceded) the urine leakage, write yes.  If you felt no urge when the leakage occurred, write no.
2. If the leakage occurred while you were sleeping write yes under wet bed column.

Day 1

Day 2

Day 3

This Chart is a record of your voiding (urinating) and leakage (incontinence) of urine.  Please follow the instructions below prior to your next visit to our office.

Instructions: Choose 3 days, not necessarily consecutive days.  Keep the record when you can conveniently measure trips to the bathroom.  Begin your record with the first voiding upon arising in the morning.

1. Record times of all intake of liquid and voids.
2. Measure all intake in ounces (1 cup = 8 ounces) or in ccs.
3. Measure all trips to the bathroom in ccs.  For example, the top number on the urine collection container we have given you is 1000 cc.

Day 1                                                               Day 2

Day 3

If you are also having problems with incontinence, fill out 2^nd diary below regarding your leakage.

1. Describe the activity you were performing at the time of leakage.  If you were not actively doing anything, record whether you were sitting, standing or lying down.
2. Estimate the amount of leakage according to the following scale:

1 = damp, a few drops only

2 = wet underwear or pad

3 = soaked or emptied bladder

1. If the urge to urinate accompanied (or preceded) the urine leakage, write yes.  If you felt no urge when the leakage occurred, write no.
2. If the leakage occurred while you were sleeping write yes under wet bed column.

Day 1

Day 2

Day 3