Name (YOUR NAME, not the name of the restaurant or event)
Address
City State ZIP

Phone PLEASE include area code
    Is this a
Daytime Phone Number
Evening Phone Number

Gender: Male Female

DOB eg: July 4, 1976

E-mail  eg: someone@somewhere.com

When did you first become ill? 

Date of FIRST vomit or diarrhea (whichever occurred first): (Date)
Time of onset: AM PM

Date of LAST day of illness with vomit or diarrhea: (Date)
Time of last episode of vomit or diarrhea: AM PM
Duration:(hours)

Please check all symptoms you experienced:

Nausea
Vomiting 
Diarrhea  If checked: Maximum number of stools in a 24-hour period:
Bloody diarrhea
Abdominal cramps 
Fever  If checked: Temperature:(°F)
Chills 
Headache 
Body aches 
Fatigue 
Constipation
Other: (List additional symptoms)

Did you see a healthcare provider (doctor/nurse)?
YES  NO -- If yes: When? (Date)
Name of Doctor/Clinic:Phone:


Did anyone in your household have a similar illness?  YES   NO
If yes, who? When?

Did anyone you know have a similar illness? YES  NO
If yes, who? When?

Did you travel anywhere during the seven days before your illness? YES   NO
If yes: Where?When? to

OTHER COMMENTS:

REMEMBER: We are unable to conduct an investigation with out your contact information.
Please check to be sure that you included your NAME, as well as either a phone number or
email address, in the event we need further information.