Foodborne Illness Complaint Intake Form

Your name:

Your phone:

Your email:

Name of the food establishment:

Address of the food establishment:

Date of the meal:

Time of meal consumption:

Food items consumed:

Did you notice anything unusual about the food?

Date of onset:

Time of onset:

Symptoms (check all that apply): Nausea Vomiting Diarrhea Chills/Sweats Cramps Fever Dizziness Other

Other symptoms (if applicable):

What beverages (if any) were consumed?

How many people were in your party?

How many became ill?

Was this a carry-out meal? Yes No

Was this a catered event? Yes No

Was a medical professional visited? Yes No

What is the medical professional or practice's name?

What is the medical professional's phone number?