Note: For your convenience, this is a printer-friendly document. We recommend that you print this page and make copies in order to have a new diary log for each day.

 

URINARY DIARY

Instructions:

 

1.  In the 1st column mark an (x) every time you urinate into the toilet.

 

2.  In the 2nd column, mark an (x) every time you accidentally leaked urine.

 

3.  If an accident occurred, indicate the reason or circumstances surrounding the accident, for example, “coughed, bent over, sudden urge.”

 

4.  Under “Fluid Intake” describe the type (coffee, tea, juice, etc.) and amount (a cup, 1 quart, etc).

 

5.  Circle the time when you went to bed and when you got up in the morning.

 

6.  Record number and type of pads used.

 

7.  Under Notes write any additional information you would like to include.  For example, type and dose of medication you may be on for your urinary incontinence.

 

Name:_________________________________  

 

Day/Date:______________________________

   

 

 

 

TIME

URINATE IN TOILET

LEAKING ACCIDENT

REASON FOR ACCIDENT

 

FLUID INTAKE

    TYPE        AMOUNT

6 a.m.

 

 

 

 

 

 

7 a.m.

 

 

 

 

 

 

8 a.m.

 

 

 

 

 

 

9 a.m.

 

 

 

 

 

 

10 a.m.

 

 

 

 

 

 

11 a.m.

 

 

 

 

 

 

12 Noon

 

 

 

 

 

 

1 p.m.

 

 

 

 

 

 

2 p.m.

 

 

 

 

 

 

3 p.m.

 

 

 

 

 

 

4 p.m.

 

 

 

 

 

 

5 p.m.

 

 

 

 

 

 

6 p.m.

 

 

 

 

 

 

7 p.m.

 

 

 

 

 

 

8 p.m.

 

 

 

 

 

 

9 p.m.

 

 

 

 

 

 

10 p.m.

 

 

 

 

 

 

11 p.m.

 

 

 

 

 

 

12 midnight

 

 

 

 

 

1 a.m.

 

 

 

 

 

 

2 a.m.

 

 

 

 

 

 

3 a.m.

 

 

 

 

 

 

4 a.m.

 

 

 

 

 

 

5 a.m.

 

 

 

 

 

 

 

 

  Number of pads used in 24 hours:
  Notes:
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Questions or comments about this Web site may be sent to
coe@obgyn.ucsf.edu. Last updated: 09/15/2009

The University of California, San Francisco, CA 94143, (415) 476-9000 Copyright © 2009, The Regents of the University of California.

 

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