HCPHES Environmental Health Services Division

Harris County Public Health and Environmental Services

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

Disclaimer

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