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The Place for Youth Health: Questions

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Food Investigation Report

Please click on the Section Headings, below, to answer questions regarding your illness.

Thank you.

Polk County Public Health
182 SW Academy St., Suite 302
Dallas, OR 97338
(503) 623-8175

_____________________________________________________________________________

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General Information

Name *

Date *

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Address *

City *

State *

Telephone Number *

Email Address *

Sex *

Male

Female

What Time Did You Eat? *

How Many Drinks With Ice Did You Have? *

Did You Have Any Drinks With Water? *

Yes

No

History (Within the Last 24 Hours)

Please list the items you ate OR drank within the last 24 hours, starting with the most recent meal.

Dinner (Include Time) *

Lunch (Include Time) *

Breakfast (Include Time) *

Did You Drink Water At Any Location Different Than Normal? *

Yes

No

If Yes, Where?

History (During the Last 24-36 Hours)

Please list all food AND drink consumed during the previous 24 - 36 hours.

Dinner (Include Time) *

Lunch (Include Time) *

Breakfast (Include Time) *

Did You Drink Water At Any Location Different Than Normal? *

Yes

No

If Yes, Where?

Please List the Name, Address & Phone Number of Anyone Else That May Have Gotten Sick

Symptoms

Please Mark if You've Experienced Any of the Following Symptoms

	Yes	No	Maybe
Headache	Headache - Yes	Headache - No	Headache - Maybe
Nausea	Nausea - Yes	Nausea - No	Nausea - Maybe
Vomiting	Vomiting - Yes	Vomiting - No	Vomiting - Maybe
Myalgias (muscle aches)	Myalgias (muscle aches) - Yes	Myalgias (muscle aches) - No	Myalgias (muscle aches) - Maybe
Abdominal (stomach, belly) Cramps	Abdominal (stomach, belly) Cramps - Yes	Abdominal (stomach, belly) Cramps - No	Abdominal (stomach, belly) Cramps - Maybe
Unusual Fatigue (feeling tired)	Unusual Fatigue (feeling tired) - Yes	Unusual Fatigue (feeling tired) - No	Unusual Fatigue (feeling tired) - Maybe
Fever**	Fever** - Yes	Fever** - No	Fever** - Maybe
Chills	Chills - Yes	Chills - No	Chills - Maybe
Diarrhea or Loose Stools***	Diarrhea or Loose Stools*** - Yes	Diarrhea or Loose Stools*** - No	Diarrhea or Loose Stools*** - Maybe

**If Fever is Present, Enter Temperature

***If Diarrhea is Present, Did You Have 3 or More Loose Stools in Any 24-Hour Period?

Yes

No

Please Describe Any Other Noteworthy Symptoms

On What Day Did You First Experience Vomiting or Diarrhea?

What Time Did You First Experience Vomiting or Diarrhea? (Be sure to include AM or PM)

If No Vomiting or Diarrhea, When Did You First Become ILL?

How Long Did You Feel Sick? (days, hours, still sick?)

Did You...

Miss Work or School? If So, How Many Days? *

Give A Stool Sample? If So, to Whom? *

See a Physician/HCP? If So, Who? *

Visit an Emergency Room? If So, Which One? *

Get Admitted Overnight to a Hospital? If So, Which One? *

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