Fluid Volume Deficit Assessment Form

Fluid Volume Deficit Assessment Form
Use this form to document symptoms, intake/losses, physical findings, and the clinical impression of fluid volume deficit.
Patient & Assessment Details
Patient Name
First NameLast Name
Patient Identifier
Age (years)
Sex/Gender
Assessment Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assessment Time
Hour Minutes
AM/PM Option
Assessor Name
First NameLast Name
Assessor Role
Primary Reason for Assessment
Fluid Intake, Losses & Symptoms
Recent oral fluid intake
Estimated oral fluid intake in the last 24 hours (mL)
Recent losses or symptoms experienced
Other
Vomiting frequency in the last 24 hours
Diarrhea frequency in the last 24 hours
Thirst level

1
2
3
4
5
6
7
8
9
10
1 is No thirst, 10 is Extreme thirst
Dizziness or lightheadedness severity

1
2
3
4
5
6
7
8
9
10
1 is None, 10 is Severe
Dry mouth severity

1
2
3
4
5
6
7
8
9
10
1 is None, 10 is Severe
Weakness severity

1
2
3
4
5
6
7
8
9
10
1 is None, 10 is Severe
Confusion severity

1
2
3
4
5
6
7
8
9
10
1 is None, 10 is Severe
Physical Assessment & Vital Signs

Vital Signs and Objective Findings

Select theme: