Bladder Diary
Please complete prior to your visit. You may stop by St. John’s outpatient lab to get a urine measuring container for your toilet if you desire. Choose a 24 hour period when it is convenient to measure and record the time and: the amount and type of fluid you drink, the amount you void (urinate), any leakage (small, medium or large), any urge to void just prior to leakage, and your activity when you leak or need to void.
For example:
Time |
Fluid intake
amount (oz.) |
Void amount
(oz.) |
Leak?
(S,M,L) |
Urge prior
to leak? |
Activity |
7:00 AM |
8 oz. coffee |
180 ml.
6 ml. |
---- |
---- |
awakening |
7:20 AM |
---- |
---- |
M |
yes |
washing my hands & face |
Adobe Acrobat Reader is required to view and print the Bladder diary or the Incontinence Questionnaire, you can download it for free by clicking on the link provided.
Download the Bladder Diary by clicking on the following link.
Bladder Dairy.pdf
Download the Incontinence Questionnaire by clicking on the following link.
Incontinence Questionnaire.pdf
If you are prompted to open the file after clicking on the link, you will need to download and install the Adobe Acrobat Reader first.
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