Modified 4/8/04

E. coli O157 and Other Shiga Toxin-Producing E. coli Questionnaire

Connecticut Emerging Infections Program

Name (Last, First): ______Age: _____ Sex: M F

City: ______County: ______Phone: ( ) _____ - ______

Parent’s name (if child): ______

E. coli “O” antigen ______“H” # ______PFGE ______Collection date: ______

Shiga-toxin positive test: yesnoPHLIS ID: ______Accession #: ______

Interviewer: ______Date: ______

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Illness History.I would like to begin by asking you about some of the symptoms you may have had.

1. Date of onset of illness : ___ /____ /______Time of onset: ____:____ AMPM

Nauseayesnodk/ns

Vomitingyes nodk/ns

Diarrheayesnodk/ns

If yes, date of onset of diarrhea: ____/____/_____ time of onset: ___:___ AM PM

Greatest # stools in a 24 hour period ______

Duration of diarrhea (days): _____

Blood in stoolyesnodk/ns

Crampsyesnodk/ns

Headacheyesnodk/ns

Feveryes nodk/ns

If yes, what was the highest temperature recorded? ______

HUSyesnodk/ns

TTPyesnodk/ns

2. Did you visit a hospital emergency room or a doctor’s office because of this illness?yesnodk/ns

If yes, number of times ______(include both ER and office/clinic visits)

3. Were you admitted to the hospital overnight for this illness?yesnodk/ns

If yes, number of nights ______Admit date: ____/____/____ Hospital: ______

4. Were you treated with antibiotics for this illness?yesnodk/ns

If yes, which antibiotic(s)? ______

5. During the 4 weeks prior to this illness, were you taking antibiotics for any reason?yesnodk/ns

If yes, which antibiotic(s)? ______

6. During the 4 weeks prior to this illness, were you taking any antacids (such as, Maalox, Tagamet, Pepcid or Zantac) on a regular basis? yes no dk/ns

If yes, which antacid(s) were you taking? ______

Open-ended Food History. Please try to remember what you may have eaten in the 5-day period before you started feeling sick. We’ll start with the day before you got sick and work backwards. (If a meal was eaten out, specify where.)

Day 1 ______, ____/____/____ (day before onset date)

Breakfast
home or out______
______ / Lunch
home or out______
______ / Dinner
home or out______
______ / Other/snacks
______

Day 2 ______, ____/____/____

Breakfast
home or out ______
______ / Lunch
home or out______
______ / Dinner
home or out______
______ / Other/snacks
______

Day 3 ______, ____/____/____

Breakfast
home or out______
______ / Lunch
home or out______
______ / Dinner
home or out______
______ / Other/snacks
______

Day 4 ______, ____/____/____

Breakfast
home or out______
______ / Lunch
home or out______
______ / Dinner
home or out______
______ / Other/snacks
______

Day 5 ______, ____/____/____

Breakfast
home or out______
______ / Lunch
home or out______
______ / Dinner
home or out______
______ / Other/snacks
______

Restaurants, Grocery Stores, Events

Now, I would like to ask you about events in the week before your illness.

7. Did you eat out at any restaurants (including take-outs, street vendors, home delivery meals) during the week before your illness? yes no dk/ns

Name ______Date ___/___/___ Time: _____ City: ______

Foods eaten: ______

Name ______Date ___/___/___ Time: _____ City: ______

Foods eaten: ______

Name ______Date ___/___/___ Time: _____ City: ______

Foods eaten: ______

Name ______Date ___/___/___ Time: _____ City: ______

Foods eaten: ______

Name ______Date ___/___/___ Time: _____ City: ______

Foods eaten: ______

8. Where did you purchase groceries that were eaten during the week before your illness (including specialty stores, produce/fruit stands, dairy marts, butcher shop, etc.)?

Name ______City ______

Name ______City ______

Name ______City ______

Name ______City ______

9. Did you attend any large gatherings (parties, festivals, fairs, etc.)?yesnodk/ns

If yes, when ___/___/___ where/type function ______

Foods eaten ______

Detailed Food History. Now, I’d like to ask about specific food items. Did you eat any of the following during the week before your illness?

Dairy ProductsComments (variety/brand, how prepared, where bought/eaten, etc.)

Milk, unpastyesnodk/ns______

Icecream, unpastyesnodk/ns______

Yogurt, unpastyesnodk/ns______

Cheese, unpastyesnodk/ns______

Soft cheesesyesnodk/ns______

brieyesnodk/nsunpasteurized? yes no dk/ns ______

queso frescoyesnodk/nsunpasteurized? yes no dk/ns ______

cottage cheeseyesnodk/nsunpasteurized? yes no dk/ns ______

creamcheeseyesnodk/nsunpasteurized? yes no dk/ns ______

fetayesnodk/nsunpasteurized? yes no dk/ns ______

mozzarellayesnodk/nsunpasteurized? yes no dk/ns ______

ricotta yesnodk/nsunpasteurized? yes no dk/ns ______

other (soft)yesnodk/nsunpasteurized? yes no dk/ns ______

Other cheesesyesnodk/nsspecify ______

Fish, Poultry, and Meats

Fishyesnodk/ns______

Shellfishyesnodk/nsspecify ______

(such as shrimp, lobster, clams, etc.)______

Chickenyesnodk/ns______

Turkeyyesnodk/ns______

Porkyesnodk/ns______

Vealyesnodk/ns______

Lambyesnodk/ns______

Venisonyesnodk/ns______

Sausageyesnodk/ns______

Hot dogyesnodk/ns______

Beef jerkyyesnodk/ns______

Dried salamiyesnodk/ns______

Steakyesnodk/ns______

Roast beefyesnodk/ns______

Other beefyesnodk/nsspecify ______

Hamburger and Ground Beef

Hamburgeryesnodk/ns______

If yes, was hamburger(s) eaten at home or out?1. at home 2. out, where ______3. both

How was the hamburger cooked?1. rare (red in middle) 2. medium (pink in middle) 3. well done (no pink)

For hamburger(s) eaten in the home, was it made from (alsoask where item was purchased from, size package, % fat, etc):

Fresh (never frozen) raw ground beefyesnodk/ns______

Previously frozen raw ground beefyesnodk/ns______

Pre-made uncooked pattiesyesnodk/ns______

Pre-made, pre-cooked pattiesyesnodk/ns______

Other ground beef such as in a taco, meatloaf, etc.yesnodk/ns______

If yes, specify dish ______, eaten at home or out, where ______

INDIRECT EXPOSURE TO HAMBURGER AND/OR GROUND BEEF IN THE HOME SETTING

If patient did not answer “yes” to eating some type of home-prepared hamburger or ground beef, ask the following.

Was there any ground beef in your refrigerator (not freezer) in the 7 days before your illness? yesnodk/ns

Did you or someone in your household prepare a meal for others that contained ground beef? yes no dk/ns

INDIRECT EXPOSURE TO OTHER RAW MEATS (ask for ALL patients)

Did you handle any raw meat at home or anywhere else in the 7 days before your illness? yes no dk/ns

If yes, what kind of meat(s) was it? ______

Salads and Vegetables

Cole slawyesnodk/ns______

Pasta saladyesnodk/ns______

Potato saladyesnodk/ns______

Pre-packaged/ yesnodk/nsspecify type/brand ______

Pre-bagged salad or lettuce______

Lettuceyesnodk/ns______

(loose leaf, whole heads, not bagged)______

Icebergyesnodk/ns______

Green leafyesnodk/ns______

Red leafyesnodk/ns______

Romaineyesnodk/ns______

Mesclun yesnodk/ns______

Other yes nodk/nsspecify type ______

Alfalfa sproutsyesnodk/ns______

Other sproutsyesnodk/nsspecify type ______

Carrotsyesnodk/nsspecify type (large, baby) ______

Cabbageyesnodk/ns______

Celeryyesnodk/ns______

Spinachyesno dk/ns______

Tomatoesyesnodk/nsspecify type (large, plum, cherry) __________

Onionsyesnodk/ns______

Radishesyesnodk/ns______

Scallionsyesnodk/ns______

(also called green onions)______

Parsleyyesnodk/ns______

Cilantroyesnodk/ns______

Basilyesnodk/ns______

Fresh Fruits

Watermelonyesnodk/nswhole or precut?______

Cantaloupeyesnodk/nswhole or precut? ______

Honeydew melon yesnodk/nswhole or precut? ______

Applesyesno dk/ns______

Grapesyesnodk/nsred or green? ______

Strawberriesyesnodk/ns______

Kiwiyesnodk/ns______

Mangoyesnodk/ns______

Pineappleyesnodk/ns______

Avocadoyesnodk/ns______

EXPOSURE TO ORGANICALLY GROWN PRODUCE

Were any of the produce (fruits and vegetables) you consumed organically grown?yesnodk/ns

If yes, what ______

Unpasteurized Juices

Apple juice/cideryesnodk/ns______

Orange juiceyesnodk/ns______

Smoothieyesnodk/nsspecify type/ingredients ______

Other juicesyesnodk/nsspecify type/ingredients ______

Drinking and Recreational Water Exposure.

11. Where does your household water supply come from?

Private wellMunicipal/city

12. Is your drinking water treated in any special way (e.g. softened, boiled, filtered)?yesnodk/ns

If yes, check all that apply: SoftenedBoiled Filtered, type of filter ______

13. Did you drink any bottled water during the week before your illness?yesnodk/ns

If yes, what brand? ______

14. Did you drink any untreated water during the week before your illness (e.g. water from pond, lake, river)?

yesnodk/ns

If yes, where______

15. Did you do any swimming or wading during the week before your illness?yesnodk/ns

If yes, what type of swimming area was it? (check all that apply)

 Wading or kiddie poolwhere ______

 Outdoor swimming poolwhere ______

 Indoor swimming pool where ______

 Hot tub, jacuzzi or spawhere ______

 Pond, lake, river or streamwhere ______

 Other where ______

Did you submerge your head under water?yesnodk/ns

Did you swallow any water?yesnodk/ns

Travel

16. Did you travel out of the country during the week before your illness?yesnodk/ns

If yes, where? ______When? from ______to ______

17. Did you travel to any other state(s)?yesnodk/ns

If yes, where? ______When? from ______to ______

Farm and Animal Exposures

18. During the 7 days before your illness, did you live on a farm?yesnodk/ns

If no, is your residence: UrbanSuburbanRural

19. Did you visit a farm or petting zoo at which there were animals?yesnodk/ns

If yes, where ______What kind of animals were there?______

20. Did you have direct contact with any farm animals? yesnodk/ns

If yes, what kind of animal(s)? ______Where ______

21. Did you do any gardening?yesnodk/ns

22. Did you have contact with animal manure (as might occur during farming or gardening)?

yes no dk/ns

If yes, what kind of activity were you involved in? ______

23. Did you have contact with household pets (including reptiles)? yes no dk/ns

If yes, what kind of animal(s) ______

Were the animal(s) sick with diarrhea?yesnodk/ns

Occupation/Daycare and Household Contact Information

If case is an adult:

What is your occupation? ______

If patient is a foodhandler, healthcare worker, childcare provider, obtain the following information:

Name of employer ______Location ______

If case is a child:

Does your child attend daycare?yesno

If yes, name of daycare ______Location ______

Did your child attend daycare while sick with diarrhea?yes no

If yes, dates attended ______

Can you tell us about other household members, their ages, occupation, and whether they have been ill with a similar illness:

NameRelationshipAgeOccupationIll (Y/N) If yes, onset & symptoms

______

______

______

______

______

Race/Ethnicity

What is your race?

WhiteBlackAsian, Pacific IslanderAmerican Indian

Other, ______RefusedDon’t know/not sure

Are you of Hispanic origin?

YesNo Refused  Don’t know/not sure