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 Medical Self - Care: 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 ____________________________ ________________ ________________ ____________
No. of pads used today: No. of episodes:
Comments: _______________________________________

About Incontinence

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