Fluid Balance Intake Form
Please record daily fluid intake and output accurately. Use this Fluid Balance Intake Form to ensure precise tracking.
Full Name
*
First Name
Last Name
Date of Record
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Total Oral Fluid Intake (ml)
*
IV Fluids Intake (ml)
Other Intake (ml)
Total Urine Output (ml)
*
Other Output (e.g., emesis, drains) (ml)
Net Fluid Balance (Intake minus Output, ml)
Notes / Comments
Submit Fluid Balance
Should be Empty: