CUPHD Illness reporting form

CUPHD - Illness Reporting Form

Please fill out this form if you have eaten at a public establishment (e.g. restaurant, wedding, cafe. etc); and had a gastroenteritis symptom such as diarrhea or vomiting.

If you wish to file a complaint regarding the cleanliness of the restaurant or against a specific employee at the restaurant, please use the Food Service Establishment complaint form.

Name: First and last Age: Sex: M or F
Address: Street address City: State: Zip code:
Home phone: Include area code Other phone: Include area code
Occupation: General description of complaint:
Location: Name of establishment
Address: Street address City: State: Zip code:
Meal eaten Date - - MM-DD-YYYY Time : HH:MM AM/PM
Description of food eaten Appetizer:
Main course:
Desert:
Drinks:
Please list all foods and beverages
Were any members of your household ill in the week before you became ill? Yes No
Did you travel in the week before you became ill? Yes No Where did you travel: Date - -
Did you go swimming in the week before you became ill? Yes No Where did you swim: Date - -
What is the source of your drinking water? Home: Work:
Do you sufferer from any food allergies? Yes No Food items you are allergic to:
Please complete your three day food history. The three day food history should include your suspected meal and the food you had consumed in the 72 hours prior to that.

Date you became sick: - -

Meal	Where was meal prepared	Time of meal	Food items/beverages
Breakfast		: :
Lunch		: :
Dinner		: :
Snack		: :

One day before you became sick:

Meal	Where was meal prepared	Time of meal	Food items/beverages
Breakfast		: :
Lunch		: :
Dinner		: :
Snack		: :

Two days before you became sick:

Meal	Where was meal prepared	Time of meal	Food items/beverages
Breakfast		: :
Lunch		: :
Dinner		: :
Snack		: :

Which of the following symptoms did you have and for how long did each symptom last (Enter 0 if you did not have a symptom and 1.5 for 1 and a half hours)

Nausea: Vomiting: Diarrhea: Fever:
Headache: Prostration: Body aches: Abdominal cramps: Prostration: extreme exhaustion, or lack of energy or power.
Temperature: Enter as either farenheight or centrigrade. Other information:
Episodes of diarrhea: Episodes of vomiting:
Date and time of first episode of diarrhea Date: - - MM-DD-YYYY Time: : HH:MM AM/PM
Date and time of last episode of diarrhea Date: - - Time: :
Date and time of first episode of vomiting Date: - - Time: :
Date and time of last episode of vomiting Date: - - Time: :
Did you call or see a physician? Yes No physician's name: Diagnosis:
Emergency room visit? Yes No Hospital name: Hospital city:
Were you hospitalized? Yes No Hospital name: Hospital city:
Admission Date: - - Release date: - -
Has a stool specimen been submitted? Yes No
Would you be willing to submit a stool specimen? Yes No
Thank you for taking the time to fill out this form. Once you click submit your information will be sent to our epidemiologist.
For further information and understanding of food borne illness or organisms visit this website at the CDC.