Bladder record chart

Download and print as a PDF (235kB pdf)

Instructions

Please read carefully

This chart will help your physiotherapist assess how your bladder functions throughout the day in order to accurately diagnose and treat your condition. Please complete the chart as accurately as possible for three days and bring the completed chart to your next appointment.

Fluid intake

Each time you have a drink, note down in each column: the time, the amount (in millilitres) and what you drank (tea, coffee, water, beer etc). To do this, measure the volume of your usual cup, glass or mug and estimate the fluid you drank by always using the same cup.

Urine passed

How much urine did you pass?

Measure, in mls, any urine passed. You will need to buy a plastic measuring jug from the chemist for this. It is important to sit properly on the toilet, holding the jug in the bowl of the toilet. This helps pelvic floor muscles to relax fully. Do not squat above the seat. Note the time in the time column, and the amount in the ‘how much urine did you pass’ column.

Did you have a strong sudden, urge to go to the toilet?

In this column, record if you experienced a strong, sudden urge to go to the toilet immediately and it felt impossible to delay the need to pass urine.

Leakages

Did you have an accident and how severe was it? If you were unable to make it to the toilet in time, causing urine to leak, record how severe the accident was by recording: D = damp, W = wet or V = very wet.

At the end of the leaflet is an example chart and blank chart for the patient to complete. Please print off the PDF version to obtain the charts.

Who do I contact for further information?