Voiding Diary
Name______
The voiding diary is a record of your voiding and leakage of urine. Please complete the record according to the following instructions. Choose a 24 hour period to keep this record when you can conveniently measure every voiding, and begin your record with the first voiding on arising, as shown in the example. You may use a 2-cup measuring cup (or any other device) to measure you urine. It can be washed in the dishwasher or discarded.
Activity- Describe the activity you were performing at the time of leakage. If you were not actively doing anything record whether you were sitting, standing or lying down.
Estimate the amount of leakage according to the following scale: 1= damp, few drops only / 2= wet underwear or pad / 3= soaked oremptied bladder
Urge- Write Yes if urge to urinate accompanied (or preceded) urine leakage
Record amount and type of all liquid intake using either ml or oz (1 cup = 8 oz = 240 ml) / Please bring this record to your next visit.
Date:
Amount
Time / Amount Voided / leaked / Activity / Urge / Intake (amount/type)
Example:
6:45am / 350 ml
8:30am / 12oz coffee
6oz orange juice
9:00am / 3 / running up stairs / No
************** / ***************** / **************** / ********************** / ** / *******************