This form is really just a scratch paper which helps you quickly record small and large amounts of liquids (sample shown in ounces) being consumed throughout the day. The total intake is then transferred to the Daily Care Checklist. This tracker can be cut apart on the dotted lines and kept in a handy place for quick reference and for entering a new amount. There are four months on each sheet. Each person’s fluid needs differ, especially in the elderly, because of different medical diagnosis, so check with the physician for the correct amount needed.
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This picture is just to give you a general idea of what the forms will look like. Turning the form into a picture has greatly reduced the quality, so there are distortions that do not appear in the actual form.