UNIT: ______DATE: ______

RESIDENT ______ROOM ______

TYPE OF FLUID ______

M O N D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

T U E S D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

W E D N E S D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

T H U R S D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

TYPE OF FLUID : SP = SUPPLEMENT TL = THICK LIQUID N = NECTAR H = HONEY R = REGULAR

RESIDENT ______ROOM ______

TYPE OF FLUID ______

F R I D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

S A T U R D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%
S U N D A Y

INITIAL/DEPT ______

FLUID ITEM 1 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 2______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 3______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 4______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

INITIAL/DEPT ______

FLUID ITEM 5 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 6______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 7 ______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100% /

INITIAL/DEPT ______

FLUID ITEM 8______

Drank Drank Drank Drank Drank

None Little Half A lot All

0% 25% 50% 75% 100%

TYPE OF FLUID : SP = SUPPLEMENT TL = THICK LIQUID N = NECTAR H = HONEY R = REGULAR