Please fill this form out as completely as possible. The items marked with an * are required and must be filled out in order to submit this form.

All information you provide will be kept confidential.

Exposure Information
* Location or establishment:
Address:
City:
State:	Zip:
* Meal eaten:	Select meal Breakfast Lunch Dinner Other
* Description of food eaten: Please include everything you consumed including drinks, condiments, etc.
* Date:	ex 04-05-2006    * Time:   am pm
* Yes No	Were you or any member of your household sick the week before you became ill?
* Yes No	Did you travel in the week before you became ill?
Location:
Date:	ex 04-05-2006
* Yes No	Did you go swimming in the week before you became ill?
Location:
Date:	ex 04-05-2006
What is the source of your drinking water?
* Home?	Municipal Bottled Well
* Work?	Municipal Bottled Well

Symptoms
* Yes No Did you experience symptoms of gastroenteritis during or after (suspected source)?
Which of the following symptoms did you have and how long (enter 1.5 for one and a half hours) did each symptom last?
* Nausea:    Yes No    hours	* Vomiting:    Yes No    hours
* Diarrhea:    Yes No    hours	* Fever:    Yes No    hours
* Headache:    Yes No    hours	* Prostration:    Yes No    hours
* Body Aches:    Yes No    hours	* Abdominal Cramps:    Yes No    hours
Temperature:
Other:
How many episodes of diarrhea, total?	How many episodes of vomiting, total?
Date and time of first symptoms of diarrhea:
Date: ex 04-05-2006	Time:   am pm
Date and time of last symptoms of diarrhea:
Date: ex 04-05-2006	Time:   am pm
Date and time of first symptoms of vomiting:
Date: ex 04-05-2006	Time:   am pm
Date and time of last symptoms of vomiting:
Date: ex 04-05-2006	Time:   am pm
* Yes No Did you call or see a physician?	Name:
Diagnosis:
* Yes No   Emergency room visit?	If yes, hospital name: City:
* Yes No   Were you hospitalized?	If yes, hospital name: City:
Admission date: ex 04-05-2006	Release date: ex 04-05-2006
* Yes No Has a stool specimen submitted?
* Yes No Would you be willing to submit a stool specimen?
In case of a food borne outbreak, we may contact you to obtain a 72 hour food history.