Bladder Diary


Name:
NRIC No:                                                                       
Date / Time Started:                                                                                                                                           
Waking Time:                                                                                                                                                                  
Sleeping Time:

INSTRUCTIONS:
(1) Drinks – measure and record each time you drink, and what kind of drinks taken.
(2) Urine – each time you pass urine, measure amount and record in mls.
(3) Wet – mark W or X each time you are wet.
(4) Keep the chart / diary for 3 days as instructed by your doctor.

Date

Day 1

Day 2

Day 3

SAMPLE

Time

Drink taken

Urine passed

Drink taken

Urine passed

Drink taken

Urine passed

Drink taken

Urine passed

6 am

 

 

 

 

 

 

 

 

7 am

 

 

 

 

 

 

 

300 mls

8 am

 

 

 

 

 

 

Coffee 200mls

100 mls

9 am

 

 

 

 

 

 

 

 

10 am

 

 

 

 

 

 

Tea 200mls

W

11 am

 

 

 

 

 

 

 

200mls

12 pm

 

 

 

 

 

 

Water 150mls

 

1 pm

 

 

 

 

 

 

 

 

2 pm

 

 

 

 

 

 

 

250mls

3 pm

 

 

 

 

 

 

Juices 100mls

 

4 pm

 

 

 

 

 

 

 

50mls
50mls

5 pm

 

 

 

 

 

 

 

 

6 pm

 

 

 

 

 

 

 

 

7 pm

 

 

 

 

 

 

Soup 300mls

150mls
W

8 pm

 

 

 

 

 

 

 

 

9 pm

 

 

 

 

 

 

 

 

10 pm

 

 

 

 

 

 

 

80mls

11 pm

 

 

 

 

 

 

 

 

12 am

 

 

 

 

 

 

 

 

1 am

 

 

 

 

 

 

 

150mls

2 am

 

 

 

 

 

 

Water 100mls

100mls
W

3 am

 

 

 

 

 

 

 

100mls

4 am

 

 

 

 

 

 

 

 

5 am

 

 

 

 

 

 

 

150mls

TOTAL

 

 

 

 

 

 

 

 

FOR MEDICAL STAFF

Total fluid intake:
Frequency:
Maximum volume passed:
Interval between voiding:

 


Total voided urine volume:
Nocturia frequency:
Incontinent episodes:

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