Patient Bladder Diary Instructions
Your doctor has given you this diary in order to assess how well the procedure may
or may not affect your bladder symptoms. It is very important to fill in this diary
as completely and accurately as possible (please complete every column, even if
your answer is “none” or “normal”). Please bring your completed diary to your
next appointment or the day of your procedure.
HOW TO COMPLETE THIS DIARY
Instructions:
• Your diary should be completed for 3 consecutive 24-hour periods during
the week before your visit. This includes night time.
• Record information for each urinary or bowel episode (e.g. for each time
you use the toilet, have accidental urinary leakage, use a catheter, etc.).
• If you had a leak but did not make it to the bathroom, fill out a separate
column for that as well.
• More than 1 page may be necessary for a 24-hour period. Please
continuously record for the entire 4 days.
• Please fill out your diary in pen.
• When measuring the amount voided, please be consistent in your unit of
measurement (e.g. oz, cc, ml). Do not switch back and forth.
• If you need a urine hat to put under the toilet seat (to measure), you can pick
one up at any Metro Urology location during business hours or at a
pharmacy. Otherwise, a measuring cup can work also.
• Do not change what you normally drink or the medication you take, unless
otherwise instructed.
If you have questions on the process, please do not hesitate to call us @
651-999-7052
BLADDER DIARY
NAME:__________________________ DOB: __________________
3 – CONSECUTIVE DAYS
Average amount of liquid taken per day: _______________
Date:
Time:
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
1. Please record the time of day, each time you go
to the toilet or have a leaking episode.
2. Please rate any leaking episode you
experienced.
None
None
None
None
None
None
None
None
Slight
Slight
Slight
Slight
Slight
Slight
Slight
Slight
Slight = a few drops
Moderate = 1-2 tablespoons (1/2-1oz/15-30cc)
Heavy = soaks pad/diaper or outer clothing
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Heavy
Heavy
Heavy
Heavy
Heavy
Heavy
Heavy
Heavy
3. Urgency?
Slight
Slight
Slight
Slight
Slight
Slight
Slight
Slight
If no urge, please describe what you were doing at
the time of leakage (cough,sneeze,etc.)
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
4. Pelvic/bladder pain:
Mild
Mild
Mild
Mild
Mild
Mild
Mild
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Severe
Loss of
Control
Loss of
Control
Loss of
Control
Loss of
Control
Loss of
Control
Loss of
Control
Loss of
Control
Loss of
Control
Loose
Loose
Loose
Loose
Loose
Loose
Loose
Loose
Soft
Soft
Soft
Soft
Soft
Soft
Soft
Soft
Solid
Solid
Solid
Solid
Solid
Solid
Solid
Solid
5. Bowel Movement
©NB/KZ 8/26/10,2013
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