Foodborne Complaint Report - Individual Case History Form   Interviewer Initials    Today’s date       ID # Interviewee’s Name      Age      Sex Male Female Address Address 2 City                              Zip Code Occupation: Phone number Symptoms:   Yes No Date Started Time Started Date Ended Time Ended Cramps Diarrhea Bloody Diarrhea Nausea Vomiting Headache Body Aches Chills Fever Other Were you hospitalized /get a confirmed diagnosis?  YES      NO Did you see your Doctor/get a confirmed diagnosis? YES      NO List any Travel History here: A 72 hour food history is needed to determine what foods may have made you ill. Please fill out the Food History form to the best of your knowledge. 72 Hour Food History Date Time Location What did you eat? Day suspect meal was eaten Breakfast Lunch Dinner Snacks/Drinks One day before suspect meal was eaten Breakfast Lunch Dinner Snacks/Drinks Two days before suspect meal was eaten Breakfast Lunch Dinner Snacks/Drinks Name and address of restaurant suspected: Date and time when the suspected food was eaten?: What foods were eaten at the suspect meal? Did anyone else you know eat the suspected food and/or dine with you?    Yes         No If someone else was with you, did they also get sick? Yes         No Additional Information:

About | Adult Health | Child Health | Environmental Health | Health Data | Health Education |
Birth & Death Records | News | Hot Topics | Events | Links | Home |
Notice of Privacy Practice