Three Day Food And Fluid Chart - Nhs Lothian

Date:

Day 3

Time of drink

meal/snack:

Three Day

Food and Fluid Chart

Please read this leaflet carefully before completing as

accurately as possible.

Bring the completed chart with you to your next

appointment. It will help us to discuss your symptoms and

plan your treatment.

Name of patient: _________________________________

Address: _______________________________________

Date of birth/CHI: ________________________________

Name of Healthcare Professional:

______________________________________________

Bladder and Bowel Nursing Team

June 2016

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Parent category: Miscellaneous