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COUNTY OF MONTEREY

HEALTH DEPARTMENT

HOW DO I?


 

November 2017 Nov 2017
S M T W T F S
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Foodborne Illness Report Form

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Please correct the field(s) marked in red below:

Important: If this is an medical emergency, please call 911 immediately. This report to the health department does not provide a diagnoses or treatment for your illness.

Please fill in all fields as completely as possible. The information that you provide will help us determine if your illness is food related and what steps need to be taken by the appropriate local health department (All information is completely confidential)

(* indicates a required field)


About You

1
First Name
 *
2
Last Name
 *
3
Age
4

 Gender

5
Home Street Address
6
City
7
State
8
Zip
9
Home Phone Number
 *
10
Work Phone
11
Cell Phone
12
email
13
Preferred Method of Contact
14
Occupation
15
How did you hear about this website?
16
Are you filing this report out for yourself?

Medical Information

17
Have you seen a health care provider for your symptoms?
18
If yes, please provide their name and contact information:
19
Do you have any food allergies or sensitivities to any foods or specific ingredients?

Symptoms

20
Date Symptoms started
 *
21
What time of day did your symptoms start?
22
How long were you sick?
23
Place a check in the box by each of your symptoms (check all that apply).
24
Which symptom did you experience first?
25
Which symptom was the worst?
26
Please describe any other symptom(s).

Exposure

27
Where (including name and address, if applicable) do you think you may have become ill?
28
What specific food did you eat that you suspect made you ill?
29
What date did you eat the specific food that you suspect made you ill?
30
What time of day did you eat the specific food that you suspect made you ill?
31
List any places where you ate food during the 4 days before the START of symptoms.
32
From the places you listed in Question 31, please list the food that you ate at those locations:
33
How many other people in your household were sick with the same symptoms around the same time as you?
34
How many other people, excluding household members, were sick with the same symptoms around the same time as you?
35
During the 4 days before the START of the symptoms, did you...
36
Attend a group event (wedding, reunion, picnics, etc.)?
37
Have contact with animals?
38
Have contact with children under the age of 5?
39

Travel outside your home country?

40
Have contact with a sick person?
41
Prepare food for other people?
42
Change a diaper?

Recent Food History

43
Providing a history of food you have recently eaten helps investigators identify potential food items that may have caused your illness. You may provide your food history below (start with four days before you became ill). You can also skip this part and a local health department representative may contact you later to gather this information to help with their investigation.

Other Notes/Comments

44
If you have any other information that you feel would be helpful for your local health Department about this case, please enter it below.
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