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Bladder Diary

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Time and Volume Record

This bladder diary is very important. It allows your doctor to see how your bladder and kidneys function.
Please take the time to complete as accurately as possible.

Instructions

Please record the following over 2 CONSECUTIVE DAYS
It is recommended you complete the bladder diary as a written copy first and then transfer the information to the online form when completed.

Time The time that you drink, pass urine or have anything to note. This can include what you were doing when the symptoms occur, e.g. urgency when putting the key in the door.
Urine passed Please measure in mL how much urine you pass each time you go to the toilet. We suggest you use a plastic measuring jug.
Drinks How much you drink. If you use 'cups' could you measure how many ml are in your standard cup.
What you drink The ingredients of some drinks irritate the bladder, e.g. cola, tea, coffee

Note if:

  1. Urine burns.
  2. You leak - You can describe it as a small, medium or large leak or just a stain on your underwear.
  3. You have a bowel action at the same time as you pass urine.
Name*
DD slash MM slash YYYY

Day 1

DD slash MM slash YYYY
Day 1 (Drink intake record)*
Time
Drink (in ml)
Type of Drink
 
To add more records, click on the + sign.
Day 1 (Urine Output Record)*
Time
Urine Passed (in ml)
Notes
 
To add more records, click on the + sign.

Day 2

DD slash MM slash YYYY
Day 2 (Drink intake record)*
Time
Drink (in ml)
Type of Drink
 
To add more records, click on the + sign.
Day 2 (Urine Output Record)*
Time
Urine Passed (in ml)
Notes
 
To add more records, click on the + sign.