Food Borne Illness Complaint Form Name(Required) First Last Email(Required) Phone(Required)Date of Visit(Required) MM slash DD slash YYYY Dine-In or Carryout DateTime of Visit(Required) Hours : Minutes AM PM AM/PM Was this a dine-in visit or take out?(Required) Dine-In Takeout Delivery Was the left over taken home?(Required) Yes No Comment(Required)Illness DataIlness Start Date(Required) MM slash DD slash YYYY Illness Start Time Hours : Minutes AM PM AM/PM Ilness Stop Date(Required) MM slash DD slash YYYY Illness Stop Time Hours : Minutes AM PM AM/PM Signs and Symptoms(Required)NauseaDizzinessDiarrheaHeadacheFeverItchingVomitingWeaknessMyalgia (muscle ache)Abdominal PainNumbnessTinglingDouble VisionEdemaJaundiceRashChillsUse CTRL or CMD (MAC) to select multiple optionsWas a healthcare provider visited?(Required) Yes No Date Visited(Required) MM slash DD slash YYYY Healthcare Facility / Physician Name(Required) Suspect Illness DataNumber of people in party(Required)Enter number onlyNumber of people ill(Required)Enter number onlyList anything unusual about the meal(Required)Describe anything about the food - temperature, texture, taste, smell, etc. Other exposuresTravel outside of the US(Required) Yes No Water consumed outside residence(Required) Yes No Exposure to recreational water?(Required) Yes No Exposure to the following:Petting zooIll person at home or outside of homeIll animalDiapered kids or adultsMass gatheringsDomestic animals or livestockBirds or reptilesVisit nursing homeDaycare FacilityUse CTRL or CMD (MAC) to select multiple options Δ
