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Environmental Public Health Division

Foodborne Illness Intake Form

 

Name of person reporting the illness:
Email Address: 
   
 

Address:    

Phone #: 

1.  Food Establishment/Source of Illness:

 
Address: 

Phone#:
 

2.  What are the names and phone numbers of person (s)
who became ill from eating at this establishment?
Name: Telephone # Occupation Age:

3. Do ill persons live in same the household?    
Yes         
No

4
.  What is the date and time that the meal was eaten? 
Date:    
Time:

5
.  Was the meal eaten at the time it was prepared?
Yes        
No

6
.  If not, when was it prepared and where was it eaten?

7
.  What was eaten?
Name Food Eaten
 

8
. What drinks were consumed?
Name Drinks Consumed


9
.  Did anyone else eat at the same place and  become ill? 
Yes  
No
Name: Telephone # Name Telephone #
 


10
.  Please mention your symptoms in the order they appeared:

Name: Symptom Date Time


11
.  How about these symptoms ( if not previously mentioned)?

Vomiting   Fever Other
Abdominal
      cramps
Headache What was the
highest temperature?
F
Diarrhea Was blood present? Body ache
Nausea     

12. How long did the gastrointestinal symptoms last?
One day or less   2 days  3 days or more

13. Were you hospitalized? 
Yes
  
No
 
If yes, where?

How long?

14.  Did the ill person see a physician?    
Yes
  No

15.  Physician's Name:

Phone #
Diagnosis:  
When seen?  
Specimens:

16.  Did two or more ill persons share any other common meal within the last three days?
Yes  
No

17.  What is the date and time that the meal was eaten?
 

18.  What foods were eaten?


19.  Were any meals eaten outside of your home over the last three days?

Name Location Date


Additional Comments:

       

 

 

Every effort will be made to keep complainant information confidential

 


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Last updated:  March 17, 2010 
Harris County Public Health & Environmental Services
2223 West Loop South
Houston, TX 77027
Tel: (713) 439-6000
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