Foodborne Illness

This questionnaire should only take about five minutes of your time. The information you provide is confidential and it is used only for public health purposes. Please provide as much information as you can recall to help us investigate and protect others from potential exposures. If you have any questions or concerns regarding this form, please contact the Communicable Disease Unit at (708) 836-8699.

PERSONAL INFORMATION
Name*
Phone*
E-mail Address*
Address*
City*
RESTAURANT INFORMATION
Name*
Address*
City*
Date Of Meal*
Time Eaten*
Food Consumed*
Any unusual or suspicious circumstances related to food consumption?*
- Yes
- No
How was the food served?*
ILLNESS
Did you experience any symptoms?*
- Yes
- No
What was the first symptom?*
Date of First Symptom*
MM slash DD slash YYYY
Time of First Symptom*
Date of Last Symptom*
MM slash DD slash YYYY
Time of Last Symptom*
Did you experience vomiting?*
- Yes
- No
How long did the vomiting last?
What was the greatest number of diarrhea episodes you had in a 24 hour period?
Did you experience a fever?*
- Yes
- No
During your fever, what was your temperature in degrees fahrenheit?
Did you experience cramps?
- Yes
- No
Did you experience chills?
- Yes
- No
Did you experience a headache?
- Yes
- No
Did you experience muscle aches?
- Yes
- No
Did you experience nausea?
- Yes
- No
Did you experience dizziness?
- Yes
- No
Did you experience dehydration?
- Yes
- No
What other symptoms did you experience?
Did you visit a Doctor or Hospital due to this illness?*
- Yes
- No
Hospital/Doctor Name
Hospital/Doctor Phone
Was a stool specimen obtained?
- Yes
- No
What was the specimen's test result?
OTHER EXPOSURES
Did you eat somewhere else in the 72 hours prior to onset?
- Yes
- No
Facility Name Address Date Time Food and Beverages Consumed
Were you with somebody else that we may need to interview?*
- Yes
- No
Name Phone
Number of People Exposed
Number of People Ill
Other Common Meals (Includes home prepared meals)
- Yes
- No
Captcha

Facility Name	Address	Date	Time	Food and Beverages Consumed

Name	Phone

Foodborne Illness

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