Continence Assessment Charts

If you have been referred to the service, please print the below and return to the team by email or post:

• fchc.continence@nhs.net
• Continence team, Consort House, 5-7 Queensway, Redhill, Surrey, RH1 1YB.

Name: 

Date of birth: 

 

This booklet contains three charts for you to complete to provide the continence team with some essential information ready for your full assessment. The charts should be completed over the same four days. These should be completed as well as the questionnaire we have sent you.

The charts will show us your bowel and bladder activity and what you eat and drink on an average day. We ask that you complete these on a 'normal' day rather than when you are on holiday or at a special occasion such as a wedding, as your eating and drinking may be different.

It is very important that we understand both your bowel and bladder activity as these impact on each other and therefore ask that you complete all three charts, not just the one which records any difficulties you are having.

For support with completing the charts, please refer to the user guide here.  If you need further guidance do not hesitate to contact us: 

• 01737 777712
• fchc.continence@nhs.net

Once the team receive your returned charts and questionnaire you will be contacted to make an appointment for your first consultation.

Fluid Diary Quick Guide:

• Fluid in Column: Any drinks or liquid food taken
• Urine Out Column: How much urine (wee) you pass
• W, L, C Column: Put 'W' if you are wet, 'L' if you leaked a bit and 'C' when you change clothing or a pad.

Day 1

Day 2

Day 3

Day 4

Date:

Date:

Date:

Date:

Time

Fluid In

Urine Out

W L or C?

Fluid In

Urine Out

W L or C?

Fluid In

Urine Out

W L or C?

Fluid In

Urine Out

W L or C?

1 am

2 am

3 am

4 am

5 am

6 am

7 am

8 am

9 am

10 am

11 am

Noon

1 pm

2 pm

3 pm

4 pm

5 pm

6 pm

7 pm

8 pm

9 pm

10 pm

11 pm

Midnight

Total:

 

 

	Time bowels opened	Amount  Small Medium Large	Consistency See Bristol Stool Scale	Any soiling Yes  No	Bowel medication Taken? What? How much? When?	Other comments
Day1  Date:
Day2  Date:
Day3  Date:
Day4  Date:

Bristol Stool Type

 

Day 1 Food Diary    

Date:

Meal time	Food eaten	Portion size
Breakfast
Time
Snack
Time
Lunch
Time
Snack
Time
Dinner/supper
Time
Snack
Time

 

Day 2 Food Diary    

Date:

Meal time	Food eaten	Portion size
Breakfast
Time
Snack
Time
Lunch
Time
Snack
Time
Dinner/supper
Time
Snack
Time

 

Day 3 Food Diary    

Date:

Meal time	Food eaten	Portion size
Breakfast
Time
Snack
Time
Lunch
Time
Snack
Time
Dinner/supper
Time
Snack
Time

 

Day 4 Food Diary    

Date:

Meal time	Food eaten	Portion size
Breakfast
Time
Snack
Time
Lunch
Time
Snack
Time
Dinner/supper
Time
Snack
Time

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us:

First Community (Head Office)

Call: 01737 775450 Email:  fchc.enquiries@nhs.net   Text: 07814 639034

Address: First Community Health and Care, Consort House, 5-7 Queensway, Redhill, Surrey, RH1 1YB.

For office use only: PFD_LTC040 Continence Assessment Charts v1 Publication January 2025