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:______________________________