Incontinence chart
Peer reviewed by Dr Helen Huins, MRCGPLast updated by Dr Laurence KnottLast updated 20 Sept 2017
Meets Patient’s editorial guidelines
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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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Article history
The information on this page is peer reviewed by qualified clinicians.
20 Sept 2017 | Latest version
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