Overview
Complete one of these records each day for several days, then take the completed records to your doctor. This information will help you and your doctor see how often you leak urine and what seems to cause the leakage.
Name:
Date:
Instructions: Place a check mark 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 or water) and estimate the amount (for example, 1 cup).
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Time interval
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Urinated in toilet
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Had a small incontinence episode
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Had a large incontinence episode
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Reason for incontinence episode
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Type/amount of liquid intake
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6–8 a.m.
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8–10 a.m.
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10 a.m.–noon
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Noon–2 p.m.
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2–4 p.m.
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4–6 p.m.
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6–8 p.m.
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8–10 p.m.
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10 p.m.–midnight
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Overnight
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Number of times urine leaked today:
Number of absorbent pads used today:
Comments:
Source: Fantl JA, et al. (1996). Urinary Incontinence in Adults: Acute and Chronic Management: 1996 Update. AHCPR Clinical Practice Guidelines, No. 2. Rockville, MD: Agency for Health Care Policy and Research (AHCPR).
Credits
Current as of:
March 1, 2023
Author: Healthwise Staff
Medical Review:
E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
Avery L. Seifert MD - Urology
