Food-Borne Illness
Case History Questionnaire
Contact Information
To which gender do you most identify?
Female
Male
Other
Age
Employment
Complaint
Suspect Meal and Location
Were there any leftovers?
Yes
No
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Duration of Symptoms
Start of Symptoms (Date/time)
End of Symptoms (Date/time)
Duration of illness
Number of ill person(s)
Number who ate food (if event/function)
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Predominant Symptoms
Predominant symptoms (check all that apply)
Vomiting
Fever
Skin (itching, flushing, rash)
Diarrhea
Nausea
Jaundice
Bloody stools
Abdominal cramps
Paralysis
Other Symptoms
Vomiting - Number of episodes in 24 hours
Diarrhea - Number of episodes in 24 hours
Fever - degrees (in Fahrenheit)
Fever - number of episodes in 24 hours
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Medical Treatment
Did you seek medical attention?
Yes
No
Doctor's Information
Were you hospitalized?
Yes
No
Were lab tests conducted?
Yes
No
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Potentially Hazardous Foods
(Specify if the following were consumed in the past 3 days)
Raw or undercooked eggs?
Yes
No
Details
Raw or undercooked meat, shellfish or fish?
Yes
No
Details
Unpasteurized milk or juice?
Yes
No
Details
Any foods canned at yours or someone else's home?
Yes
No
Details
Fresh fruit or vegetables?
Yes
No
Details
Soft cheese made from unpasteurized milk?
Yes
No
Details
Samples from a grocery store or warehouse?
Yes
No
Details
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Exposure history within the past 6 weeks.
Exposure history within the past 6 weeks.
Any international travel? (e.g. Europe, Mexico, etc.)
Yes
No
Specify country
Any domestic travel? (i.e. Kalispell, Spokane, any where in the United States)
Yes
No
Specify location
Have you been in a daycare or around children in diapers?
Yes
No
Specify location and relation:
Have you been around someone who has been sick?
Yes
No
Specify illness if known
Have you been around any pets, livestock, reptiles, or ill animals?
Yes
No
Details
What is your drinking water source?
City
Private Well
Has it been tested?
Yes
No
Do you have any medical conditions or are taking any medications that may affect your digestive system?
Yes
No
Details
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Others Possibly Exposed
Exposure history within the past 6 weeks.
Are you aware of other people with symptoms?
Yes
No
Please explain
Please have them contact us at 406-258-4755 or by sending us a Food Borne Illness Complaint Form.
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Exposure History Within the Past 6 Week continued
Have you attended any large functions or events? (e.g. BBQs, reunions, picnics, etc.)
Yes
No
Specify location
Was there food?
Yes
No
What food was offered?
Was the event catered?
Yes
No
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Caterer
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72 Hour Food History Day 1
List all foods and beverages consumed 72 hours (3 days) before the start of your symptoms. (Include all food establishments where food was eaten, but not implicated.) (Include snacks, drinks, water, supplements, etc.)
Date
Breakfast
Lunch
Dinner
Snacks/Other
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72 Hour Food History Day 2
List all foods and beverages consumed 72 hours (3 days) before the start of your symptoms. (Include all food establishments where food was eaten, but not implicated.) (Include snacks, drinks, water, supplements, etc.)
Date
Breakfast
Lunch
Dinner
Snack
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72 Hour Food History Day 3
List all foods and beverages consumed 72 hours (3 days) before the start of your symptoms. (Include all food establishments where food was eaten, but not implicated.) (Include snacks, drinks, water, supplements, etc.)
Date
Breakfast
Lunch
Dinner
Snack
Submit
Should be Empty: