Patient Forms · Before your visit

Bladder Diary

If your doctor asked you to keep a bladder diary, print this and fill it in for three days, one page per day, then bring it to your visit.

This form is for paper. Print it, fill it in, and bring it to your visit. Nothing you type on this page is sent or saved.

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Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Bladder DiaryDIARY-1 · v2026.11.0

Bladder Diary

Three days · DIARY-1 · v2026.11.0

About you

First name

Last name

Date of birth

MM/DD/YYYY

How to keep your diary

INSTRUCTIONS

Keep the diary for three days in a row — any three days that are typical for you. Start when you get up on Day 1.

Each time you urinate, write the time and how much you passed. Use a measuring cup or a collection container if your doctor gave you one, and write the amount in ounces (oz) or milliliters (mL). If you cannot measure, write “U” for urinated.

Each time you drink, write the time, what you drank and roughly how much (for example: coffee, 8 oz).

If you leak, write the time and how much: D = a few drops, M = moderate, S = soaked. Note what you were doing at the time (for example: coughing, lifting, on the way to the bathroom).

Rate how strong the urge to urinate was: 0 = no urge, 1 = mild, 2 = moderate, 3 = strong (could not wait).

Write down the time you went to bed and the time you got up, and how many pads you used each day. Include trips to the bathroom during the night.

Bring the completed diary to your visit.

Questions? Call (305) 672-4222.

Day 1

Date

MM/DD/YYYY

Time you got up

Time you went to bed

Pads used today

Day 1 — one line each time you urinate, drink or leak

Time 1Urinated (oz or mL) 1Drinks (type and amount) 1Leak D/M/S 1Urge 0–3 1Activity at leak 1

Time 2Urinated (oz or mL) 2Drinks (type and amount) 2Leak D/M/S 2Urge 0–3 2Activity at leak 2

Time 3Urinated (oz or mL) 3Drinks (type and amount) 3Leak D/M/S 3Urge 0–3 3Activity at leak 3

Time 4Urinated (oz or mL) 4Drinks (type and amount) 4Leak D/M/S 4Urge 0–3 4Activity at leak 4

Time 5Urinated (oz or mL) 5Drinks (type and amount) 5Leak D/M/S 5Urge 0–3 5Activity at leak 5

Time 6Urinated (oz or mL) 6Drinks (type and amount) 6Leak D/M/S 6Urge 0–3 6Activity at leak 6

Time 7Urinated (oz or mL) 7Drinks (type and amount) 7Leak D/M/S 7Urge 0–3 7Activity at leak 7

Time 8Urinated (oz or mL) 8Drinks (type and amount) 8Leak D/M/S 8Urge 0–3 8Activity at leak 8

Time 9Urinated (oz or mL) 9Drinks (type and amount) 9Leak D/M/S 9Urge 0–3 9Activity at leak 9

Time 10Urinated (oz or mL) 10Drinks (type and amount) 10Leak D/M/S 10Urge 0–3 10Activity at leak 10

Time 11Urinated (oz or mL) 11Drinks (type and amount) 11Leak D/M/S 11Urge 0–3 11Activity at leak 11

Time 12Urinated (oz or mL) 12Drinks (type and amount) 12Leak D/M/S 12Urge 0–3 12Activity at leak 12

Time 13Urinated (oz or mL) 13Drinks (type and amount) 13Leak D/M/S 13Urge 0–3 13Activity at leak 13

Time 14Urinated (oz or mL) 14Drinks (type and amount) 14Leak D/M/S 14Urge 0–3 14Activity at leak 14

Time 15Urinated (oz or mL) 15Drinks (type and amount) 15Leak D/M/S 15Urge 0–3 15Activity at leak 15

Time 16Urinated (oz or mL) 16Drinks (type and amount) 16Leak D/M/S 16Urge 0–3 16Activity at leak 16

Time 17Urinated (oz or mL) 17Drinks (type and amount) 17Leak D/M/S 17Urge 0–3 17Activity at leak 17

Time 18Urinated (oz or mL) 18Drinks (type and amount) 18Leak D/M/S 18Urge 0–3 18Activity at leak 18

Time 19Urinated (oz or mL) 19Drinks (type and amount) 19Leak D/M/S 19Urge 0–3 19Activity at leak 19

Time 20Urinated (oz or mL) 20Drinks (type and amount) 20Leak D/M/S 20Urge 0–3 20Activity at leak 20

Time 21Urinated (oz or mL) 21Drinks (type and amount) 21Leak D/M/S 21Urge 0–3 21Activity at leak 21

Time 22Urinated (oz or mL) 22Drinks (type and amount) 22Leak D/M/S 22Urge 0–3 22Activity at leak 22

Time 23Urinated (oz or mL) 23Drinks (type and amount) 23Leak D/M/S 23Urge 0–3 23Activity at leak 23

Time 24Urinated (oz or mL) 24Drinks (type and amount) 24Leak D/M/S 24Urge 0–3 24Activity at leak 24

Time 25Urinated (oz or mL) 25Drinks (type and amount) 25Leak D/M/S 25Urge 0–3 25Activity at leak 25

Time 26Urinated (oz or mL) 26Drinks (type and amount) 26Leak D/M/S 26Urge 0–3 26Activity at leak 26

Time 27Urinated (oz or mL) 27Drinks (type and amount) 27Leak D/M/S 27Urge 0–3 27Activity at leak 27

Time 28Urinated (oz or mL) 28Drinks (type and amount) 28Leak D/M/S 28Urge 0–3 28Activity at leak 28

Time 29Urinated (oz or mL) 29Drinks (type and amount) 29Leak D/M/S 29Urge 0–3 29Activity at leak 29

Time 30Urinated (oz or mL) 30Drinks (type and amount) 30Leak D/M/S 30Urge 0–3 30Activity at leak 30

Day 2

Date

MM/DD/YYYY

Time you got up

Time you went to bed

Pads used today

Day 2 — one line each time you urinate, drink or leak