Create a Website Account - Manage notification subscriptions, save form progress and more.
Please indicate AM or PM
Check all that apply
If you did not take your temperature put "unknown"
Name and Address of Hospital, Prompt Care, or Doctor
Please encourage all who are ill to also complete this form.
(dog, cat, fish, turtle, bird, etc.)
You can select more than one answer
Please list all places you shop for groceries at. Please include the location of the grocery store.
Please include where you buy the product.
The 72 hour Food History is the most important part of your complaint. With all the information we are collecting with your illness symptoms, it will help us best determine the likely source of your illness.
• Try to remember what food items you ate on each day to the best of your ability.
• Please include all ingredients. For instance, instead of "turkey sandwich," it is more helpful to let us know you ate a turkey sandwich which had sliced deli turkey, colby jack cheese, lettuce, tomato, cucumber, mustard, and wheat bread.
• Also, remember to include all beverages consumed and whether you had ice in your beverage.
• Please include cooking preferences for undercooked food items. Example: hamburger- cooked medium, eggs- sunny side up, or tuna- seared edges.
• If you did not eat or do not remember what you ate; select "other".
If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.
Please be as detailed as possible about foods consumed- include toppings, condiments, etc.
This field is not part of the form submission.
* indicates a required field