Illness Complaint Form

Illness Complaint Form
Keep in mind it may take hours or days before you develop symptoms so the source of your illness may NOT be the last place that you ate. Please provide a complete food history. Make sure the provided contact information is accurate so Health Department can contact you to verify submitted information.
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age
When is the best day of the week to contact you?
When is the best time of day to contact you?
Gender

Male Female Other

Meal History

Onset day

1 Day Before onset

2 Days Before onset

Breakfast

Lunch

Dinner

Other

Do you have other close contacts with similar symptoms?

Yes No Unsure
Others eating the same suspect meal or ill with similar symptoms. (Name, phone, were they ill, what did you both eat)

Have you had any group meals, banquets, pot-lucks, etc in the week before onset of symptoms?
Do you consume unpasteurized milk or other unpasteurized dairy products?

Yes No
What is your source(s) of drinking water?
Have you been to any areas where you may have consumed untreated water (summer home, rural home with well water, mountain community, etc.)?
Have you had any recreational water exposures (hot tubs, swimming pools, spray pads, water parks, lakes, rivers, etc.)?
Have you had any exposure to animals at home or elsewhere in the week before your illness?
Did you travel prior to your illness (either outside or inside US)?
Where did you purchase groceries, meat, dairy and produce for your home?
Other comments
Should be Empty: