Harvey Group Practice

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Health Information

Incontinence/Bladder Chart

Incontinence/Bladder Chart

This form is to: 1) Record the times you pass urine, 2) Record the amount of urine you pass on each occasion and 3) Record the times you leak urine (are incontinent).

  • Tick (to the nearest hour) each time you go to the toilet to pass urine.
  • If your doctor or nurse asks, when possible, also record the amount (volume) of urine you pass each time. You can use a household measuring jug to do this. If you are away from home and it is inconvenient to measure the amount then just record the time with a tick.
  • If you leak urine unintentionally, record the times it happens (to the nearest hour). Put one, two or three + signs in the box. + = damp. ++ = wet. +++ = soaking.
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Further help & information

Bladder Health UK

17 School Road, Birmingham, B28 8JG

Tel: 0121 702 0820

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Tim Kenny
Current Version:
Dr Laurence Knott
Peer Reviewer:
Dr Helen Huins
Document ID:
4770 (v40)
Last Checked:
03/11/2016
Next Review:
03/11/2019