FREQUENCY & VOLUME CHART
FOR HOSPITAL STAFF ONLY:
please complete & return the separate summary sheet for this diary.
To be put on trust headed paper, with name & number of local contact (i.e. research nurse, P.I.)
INSTRUCTIONS
This chart is a very important part of the preparation you need for your appointment regarding your bladder problem. It will help provide your doctor/nurse with information that may relate to your symptoms and will be useful in making a diagnosis and providing treatment.
It is essential that you complete the chart and bring it with you to your appointment.
Please continue your normal schedule of eating/drinking and activity so we have a record of how much you normally drink (fluid intake), how much urine you make, and how often you empty your bladder on a daily basis.
• Choose 3 days (entire 24 hrs) to complete this chart – they DO NOT have to be 3 days in a row.
• Pick days which will be convenient for you to measure and record everything that pertains to you on the chart.
• A plastic measuring cup, small bowl or urinal can be used to measure your urine volume each time you empty your bladder. You want something that will be easy to carry with you.
We have designed a diary so that you can record, everyday for three days, the:
· Number of times you have something to drink (e.g. 2 cups of tea, I mug of coffee, a can of coke, 2 glasses of wine/squash, 1 pint of beer).
· Number of times you use the toilet to pass urine.
· Number of times you leak urine when you don’t mean to or notice leakage.
· Severity of urgency you have.
· Start a new sheet for each new day.
If possible, make a record of each of the above just after they happen in case you forget to record them later on. (Hint: a reminder note stuck on a mirror in your bathroom, bedroom or kitchen may help). Each sheet in the diary covers a 24 hour period starting at 6 am and finishing at 5 am the next morning.
Each row refers to a one hour period (e.g. 6.am to 7 am, 8 pm - 9 pm). If you have a cup of tea at 9.45am record this in the 9.00am row. When you get up the next morning don’t forget to record what happened overnight on the sheet.
d / d / m / m / m / y / y / y / y
h / h / m / m
When did you get up? When did you go to bed?
Type of day: physically active yes no
Time / Tick
when
you go to the toilet / Voided urine volume (cc or mls) / Amount leaked
0=dry
1=drops/damp
2=wet-soaked
3=emptied bladder / Pad changeyes/no / Leak during
activity
yes/no / Urgency
0=none
1=mild 2=moderate 3=severe / Fluid intake and type
6.00
7.00
8.00
9.00
10.00
11.00
12 noon
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
12
midnight
01.00
02.00
03.00
04.00
05.00
d / d / m / m / m / y / y / y / y
h / h / m / m
When did you get up? When did you go to bed?
Type of day: physically active yes no
Time / Tick
when
you go to the toilet / Voided urine volume (cc or mls) / Amount leaked
0=dry
1=drops/damp
2=wet-soaked
3=emptied bladder / Pad changeyes/no / Leak during
activity
yes/no / Urgency
0=none
1=mild 2=moderate 3=severe / Fluid intake and type
6.00
7.00
8.00
9.00
10.00
11.00
12 noon
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
12
midnight
01.00
02.00
03.00
04.00
05.00
d / d / m / m / m / y / y / y / y
h / h / m / m
When did you get up? When did you go to bed?
Type of day: physically active yes no
Time / Tick
when
you go to the toilet / Voided urine volume (cc or mls) / Amount leaked
0=dry
1=drops/damp
2=wet-soaked
3=emptied bladder / Pad changeyes/no / Leak during
activity
yes/no / Urgency
0=none
1=mild 2=moderate 3=severe / Fluid intake and type
6.00
7.00
8.00
9.00
10.00
11.00
12 noon /
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
12
midnight
01.00
02.00
03.00
04.00
05.00
0 / 1 / D / E / C / 2 / 0 / 1 / 0
0 / 8 / 0 / 0
2 / 2 / 3 / 0
When did you get up? When did you go to bed?
Type of day: physically active yes no
Time / Tick
when
you go to the toilet / Voided urine volume (cc or mls) / Amount leaked
0=dry
1=drops/damp
2=wet-soaked
3=emptied bladder / Pad changeyes/no / Leak during
activity
yes/no / Urgency
0=none
1=mild 2=moderate 3=severe / Fluid intake and type
6.00 / / 50ml
100ml / 0 / no / no / 1
0 / 2 cups tea
can coke
7.00 / / 30 ml / 1 / yes / no / 0
8.00 / 1 / yes / yes / 0
9.00 / / 30ml
35ml / 1
2 / yes
yes / no / 2
3 / mug coffee
10.00 / large glass milk
11.00
12.00 / / 100ml / 0 / no / no / 1 / bowl soup
2 pints beer