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.
Further help & information
Dr Tim Kenny
Dr Hayley Willacy
Now read about Urinary Incontinence