HEALTH DEPARTMENTQUESTIONNAIRE

Administer to people who attended the John and Sally Brown Wedding on April 20th

A number of persons who attended the John and Sally BrownWedding Reception at The Chile Club in Pueblo on April 20thdeveloped gastrointestinal illness after the event.In order to determine the cause of illness, we are asking everyone who attended the wedding to complete a brief questionnaire. YOUR HELP in completing this questionnaire (whether or not you or your child were ill) IS IMPORTANT to identify the cause of the illness, and prevent future illness in others.

Participant’s name: ______Age______Sex : M F

Address:______City______

Phone numbers (home)______(work)______

  1. Were you/your child ill BEFORE the event? Yes____ No_____ Unknown _____

Describe symptoms______

  1. Have you/your child become ill with gastrointestinal symptoms SINCE attending the EVENT?

Yes______No______Unknown ______If no, please skip to question #7.

  • If yes, what symptom did you/your child experience first: ______
  • If yes, when did symptoms begin? Please be as precise as possible.

Onset Date: ____ / ____ / ____ Onset time: ______AM/PM

  1. Did you/your child experience any of the following symptoms

(please answer Y=Yes, N=No or Unsure for EACH symptoms listed below):

NauseaYNUnsure

VomitingYNUnsure

DiarrheaYNUnsure

If yes,Maximum number of stools in a 24-hour period: ______

Bloody diarrheaYNUnsure

Abdominal crampsYNUnsure

Fever YNUnsure Temp: ______°F

ChillsYNUnsure

HeadacheYNUnsure

Body achesYNUnsure

FatigueYNUnsure

ConstipationYNUnsure

Other:YNUnsure

If yes, list other symptoms: ______

  1. Are you/your child still experiencing symptoms? YN Unknown
  2. How long did your/your child’s symptoms last? ______HOURS
  3. If ill, did you/your child see a physician regarding your illness? YN Unknown

Date of visit: ______Physician Name: ______

Diagnosis by physician______Laboratory tests done: Y N UnknownType: ______

Test Results______

Type of medication given______

  1. PLEASE CHECK FOOD ITEMS YOU/YOUR CHLD ATE AT THE EVENT (please answer Y=Yes, N=No or Unsure for EACH food listed below):

Ham YN Unsure

Mashed Potato YNUnsure

Gravy YNUnsure

Mixed Vegetables YNUnsure

SaladYNUnsure

Tomatoes YNUnsure

Cucumber YNUnsure

Ranch Dressing YNUnsure

Italian Dressing YNUnsure

Thousand Island YNUnsure

Roll YNUnsure

ButterYNUnsure

Carrots YNUnsure

Celery YNUnsure

Black Olives YNUnsure

Calamata Olives YNUnsure

Green Spanish Olives YNUnsure

Greek Olives YNUnsure

Canned Artichoke Hearts YNUnsure

Roasted Garlic YNUnsure

Cheese Ball YNUnsure

Crackers YNUnsure

Cranberry Drink YNUnsure

Orange Drink YNUnsure

Tea YNUnsure

Coffee YNUnsure

Water YNUnsure

Ice YNUnsure

Chocolate Fountain YNUnsure

Strawberries YNUnsure

Grapes YNUnsure

Kiwi YNUnsure

Pound Cake YNUnsure

Cookies YNUnsure

Wedding Cake YNUnsure

  1. Did anyone in your household who did NOT attend the EVENT become ill with similar symptoms?

Y N Unknown Who?______When did they become ill? ______

THANK YOU FOR YOUR ASSISTANCE.

If you have questions, please call: XXXXXXX

The designated contact person at the XX Health Department, (XXX) XXX-XXXX

The designated contact person at the XXX Department of Public Health and Environment, (XXX) XXX-XXXX

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