Medical Self - Care: Sample Bladder Record

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Medical Self - Care: Sample Bladder Record

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Time interval	Urinated in toilet	Had a small incontinence episode	Had a large incontinence episode	Reason for incontinence episode	Type/amount of liquid intake
NAME: ____________________________________________
DATE: ____________________________________________
INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example, coffee, water) and estimate the amount (for example, one cup).
6-8 a.m.	____________	________________	________________	________________	____________
8-10 a.m.	____________	________________	________________	________________	____________
10-noon	____________	________________	________________	________________	____________
Noon-2 p.m.	____________	________________	________________	________________	____________
2-4 p.m.	____________	________________	________________	________________	____________
4-6 p.m.	____________	________________	________________	________________	____________
6-8 p.m.	____________	________________	________________	________________	____________
8-10 p.m.	____________	________________	________________	________________	____________
10-midnight	____________	________________	________________	________________	____________
Overnight	____________	________________	________________	________________	____________

No. of pads used today:			No. of episodes:

Comments: _______________________________________

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