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Tables and Figures

September/October 2003 - Mentioning the Unmentionables


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Table 1

Bladder & Bowel Record

(3 day Consecutive Assessment)      

 

Name:__________________________________      Date: ________________

 

 

 

Time of Day

Voided in

toilet

(ü)

Aware of

urge to void?

Did resident

leak urine?

(circle one) *

Activity when leakage happened (coughing, on way to the bathroom)

 

Bowel

Movement +

 

 

Fluid intake in cups

7:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

8:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

9:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

10:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

11:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

12:00 noon

 

Yes  No

S     M     L

 

F    H    L

 

1:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

2:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

3:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

4:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

5:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

6:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

7:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

8:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

9:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

10:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

11:00 p.m.

 

Yes  No

S     M     L

 

F    H    L

 

12 midnight

 

Yes  No

S     M     L

 

F    H    L

 

1:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

2:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

3:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

4:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

5:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

6:00 a.m.

 

Yes  No

S     M     L

 

F    H    L

 

Product  Worn:             __  Pad       __  Pantyliner         __  Brief         __ Other (specify)_____________

 *       S = Slightly wet     M = Wets most of pad     L = Outside of clothing is wet

+        F = Formed              H = Hard                            L = Loose/liquid

 

 Reviewed By:__                                                                                              ________

©1999 Diane K. Newman



 
 

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