Surname First Name M.I. Age Sex Civil Status Admission No.

Attending Physician

Diagnosis Room/Ward

INTAKE and OUTPUT SHEET

Date/ INTAKE OUTPUT
Shift

Oral NGT I.V. Others Total Urine Stool Others Total

10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6

6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2

2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
TOTAL

Intake = ______________
-
Output = ______________
TOTAL