Daily Intake Output Form
Record daily fluid and food intake, as well as output, for accurate monitoring.
Date of Record
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient/Resident Full Name
*
First Name
Last Name
Patient ID or Room Number
Time of Entry
*
Hour Minutes
AM
PM
AM/PM Option
Type of Intake
*
Please Select
Water
Juice
Milk
Soup
Solid Food
IV Fluid
Other (specify)
Amount of Intake (ml or g)
*
Type of Output
*
Please Select
Urine
Stool
Emesis (Vomiting)
Drainage
Other (specify)
Amount of Output (ml or g)
*
Consistency/Description of Output
Please Select
Clear
Cloudy
Bloody
Loose
Formed
Other (specify)
Special Observations or Notes
Recorded By (Name)
Submit Record
Should be Empty: