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A. This chart is designed to assess how often you pass urine by day and by night. It will help
us diagnose and treat your urinary symptoms.
The chart should be completed over five (at least 3) consecutive, fairly typical days (choose any
seven days to suit you).
A. You will need a measuring jug in order to measure the urine you pass. This should be calibrated in millilitres (ml) and should hold at least 500ml.
A. Record how much you drink (in millilitres, if possible) and enter this into the appropriate time slot of the ‘Input’ section.
Each time you pass urine, measure the amount in your jug and record it in the ‘Output’ section.
If you are unable to measure the amount for any reason, simply tick the appropriate box.
Put a line on the chart at the time you go to bed, so that we can tell how many times you have to get up at night to pass urine (nocturia).
A. If you have any leakage, please mark the box accordingly:
+ for a small amount
++ for a moderate amount
+++ for a large amount
