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Printed at: 08:23:15 / 15-05-2021

Bladder Diary

Please note, this page is printable by selecting the normal print options on your computer.

You have been asked to complete this bladder diary and bring it to your next appointment. It gives an essential picture of how your bladder is working. If you have been unable to complete all 3
days for unavoidable reasons, please still bring it with you to your appointment. Please ensure you fill in the date at the top of each day, and note your bedtime and getting up time (rise).

Example:

How to fill in this diary:
• Measure the amount of fluid you drink (in mls) and record it in the ‘drink’ column
• Add a note of what the drink is
• Measure the amount of urine passed in mls and record it in the ‘out’ column (you may wish to purchase a cheap plastic jug for this purpose). If you are occasionally unable to measure, then put a tick.
• If you have an accidental leak of urine put a W in the ‘leak’ column. If it is just a few drops, write W+; moderate leak, write W++; if you are soaked, write W+++
• If you have ‘urge’ then please mark all the episodes you have during the day (add + signs for how urgent). Record for 3 days – do your best to make this, 3 days in a row, otherwise any 3 days are
better than not completing the form.