WATER
Patient Questionnaire
Please answer all questions in this form.
------HYDRATION STATUS ------
. How many glasses (8 ounces) of plain water do you drink each day? ____
. Do you like the taste of water in general? q Y q N
. Do you like the taste of the water you drink at:
Home q Y q N Work q Y q N School q Y q N
. Do you like to have water qBefore mealsqWith meals qAfter Meals
. What color is your urine first thing in the morning usually?
q Red q Brownish q Dark yellow q Straw q Clear
. Are you on any prescription medication? q Y q N
. Do you feel like you are thirsty all of the time? q Y q N
. Do you suffer from day time fatigue? q Y q N
. Do you urinate frequently?
q Y q N If yes, how many times a day? ______
. During the work week, how many hours a day do you spend in the following places?
Home ______Work______School ______In the car ______Outdoors ______
. Recently have you spent a lot of time working outside? q Y q N
. Do you exercise on a regular basis? q Y q N
------TYPES OF FLUIDS ------
. What type of water do you use at home?
q Distilled water q Spring water q Glacier water q Boiled water q Tap water
. What type of water do you use at work?
q Distilled water q Spring water q Glacier water q Boiled water q Tap water
. How many cups of coffee do you drink each day? ______
What type of coffee? q Black q Regular q Decaf
. Do you drink herbal tea?
q Y q N If so, how often______What type? ______
. Do you drink caffeinated sodas? q Y q N
If Yes, What types? ______
. Do you drink non-caffeinated sodas? q Y q N
If Yes, What types? ______
. How many times a day do you drink fruit juices? ______
What size? ______What type? ______
. Do you use sports drinks?
q Never q Rarely q Sometimes q Frequently
. Do you drink any of the following?
q Milk q Milkshakes q Ensure q Other protein drinks
. Which of the following do you have?
q Bottled water dispenser q Sports bottle q Wearable bottle q Frequently
q Distiller q Water container at work q Water filter at home
q Water container at work q Filtered water at work