Keep a diary of your urinary leaks to help your physician to better understand your condition.

1. Voiding Diary Name:
The Voiding Diary provides useful information to your physician to better understand your condition.
Please complete this diary and give it to your physician on your next appointment.
Instructions: Example:
Try to keep an accurate record of your fluid intake, voiding and urine leakage for at least 3 days and nights Day 1 – Date: August 26
(24‐hour periods). We recommend that you pick days that will be convenient for you to measure every void. Time Amount Leakage* Activity Fluid
Measure voids using a graduated container or a voiding hat1: record the amount of urine voided in mL, cc’s or voided small (S) intake
ounces, but be consistent with your recording. Enter your result in the “Amount Voided” column (refer to (mL, cc average (A) (mL, cc
example). or oz.) large (L) or oz.)
When urine leaks occurs, record the time that the incident happened, indicate the amount of leakage (small S, 07:00am 350 mL ---- ---- 250 mL coffee
average A or large L) in the “Leakage” column, and your activity during the leak.
Measure fluid intake in mL, cc’s or ounces and record it in the “Fluid Intake” column. 08:30am ---- S jogging 150 mL water
1
Voiding hat: A container for collecting and measuring urine. This is available at most pharmacies.
Day 1 – Date: Day 2 – Date: Day 3 – Date:
Time Amount Leakage* Activity Fluid Time Amount Leakage* Activity Fluid Time Amount Leakage* Activity Fluid
voided intake voided intake voided intake
* Leakage: small (S): drops average (A): wet, soaked large (L): bladder emptied
Please note that this voiding diary is a tool to encourage doctor‐patient communication, and should never be a substitute for medical evaluation and diagnosis. Always consult a physician or healthcare professional who is
qualified to assess your health.
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