Individual Illness and 72 hour Food History Question Title * 1. Name: OK Question Title * 2. Gender: Male Female OK Question Title * 3. Age: OK Question Title * 4. Home Address: OK Question Title * 5. City, State, Zip Code OK Question Title * 6. Phone #: OK Question Title * 7. Do you have any medical conditions? yes no If yes, please explain: OK Question Title * 8. Were you taking any antibiotics prior to the onset of symptoms? yes no OK Question Title * 9. When did you begin experiencing symptoms? Date / Time Date OK Question Title * 10. What symptoms did you experience? Cramps Diarrhea Blood in stool Pale, fatty stool Gas/Bloating Nausea Vomiting Headache Body aches Fever Weight Loss Chills Fatigue Loss of Appetite Other (please specify) OK Question Title * 11. When did the symptoms stop? Date / Time Date OK Question Title * 12. While you were ill, did you seek medical attention (e.g. hospital or doctor's office)? yes no OK Question Title * 13. Was a stool specimen collected? yes no If yes, results of lab test: OK Question Title * 14. Were you hospitalized overnight? yes no OK Question Title * 15. Did anyone in your household have a similar illness? Yes No If yes, who? OK Question Title * 16. Did you attend any social gatherings during the seven days leading up to your illness? (i.e. church, festival, wedding, conference, birthday party) Yes No If yes, please list the name and date of the event(s): OK Question Title * 17. Please list all food items consumed and food establishments visited during the 72 hours leading up to the onset of symptoms: 24-0 hours (1 day ) before start of symptoms: 48-24 hours (2 days) before start of symptoms: 72 to 48 hours (3 days) before start of symptoms: OK Question Title * 18. Did you swim during the seven days leading up to your illness? Yes No If yes, where? OK Question Title * 19. From what sources of water did you drink in the seven days leading up to your illness? Tap water Well water Untreated water Bottled water Other (please specify) OK Question Title * 20. Did you have contact with anyone else who was ill during this time frame? yes no If yes, please explain: OK DONE