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?