Incontinence/Bladder Chart

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This form is to: 1) Record the times you pass urine, 2) Record the amount of urine you pass on each occasion and 3) Record the times you leak urine (are incontinent).

  • Tick (to the nearest hour) each time you go to the toilet to pass urine.
  • If your doctor or nurse asks, when possible, also record the amount (volume) of urine you pass each time. You can use a household measuring jug to do this. If you are away from home and it is inconvenient to measure the amount then just record the time with a tick.
  • If you leak urine unintentionally, record the times it happens (to the nearest hour). Put one, two or three + signs in the box. + = damp. ++ = wet. +++ = soaking.
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Original Author:
Dr Tim Kenny
Current Version:
Peer Reviewer:
Dr Helen Huins
Document ID:
4770 (v40)
Last Checked:
03/11/2016
Next Review:
03/11/2019
The Information Standard - certified member
Now read about Urinary Incontinence

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