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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".

On the day you became ill, what meals did you eat? (mark all meals consumed)*

Breakfast
Morning Snack

Lunch
Afternoon Snack

Dinner
Evening Snack

Other

On the date of your illness, where did you eat breakfast*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for breakfast*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

On the date of your illness, where did you eat the morning snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for the morning snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

On the date of your illness, where did you eat lunch*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for lunch*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

On the date of your illness, where did you eat the afternoon snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for the afternoon snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

On the date of your illness, where did you eat dinner*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for dinner*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

On the date of your illness, where did you eat the evening snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day of your illness, what did you eat for the evening snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Other

What else did you eat? Please include where you ate it at and the approximately time you ate it.*

What meals did you eat on the day before you got ill? (mark all meals consumed)*

Breakfast
Morning Snack

Lunch
Afternoon Snack

Dinner
Evening Snack

Other

The day before your illness, where did you eat breakfast?*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day before your illness, what did you eat for breakfast*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

The day before your illness, where did you eat the morning snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day before your illness, what did you eat for the morning snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

The day before your illness, where did you eat lunch*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day before your illness, what did you eat for lunch*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

The day before your illness, where did you eat the afternoon snack*

On the day before your illness, what did you eat for the afternoon snack*

The day before your illness, where did you eat dinner*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day before your illness, what did you eat for dinner*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

The day before your illness, where did you eat the evening snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

On the day before your illness, what did you eat for the evening snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Other*

What else did you eat? Please include where you ate it at and the approximately time you ate it.*

What meals did you eat two days before you got ill? (Mark all meals consumed)*

Breakfast
Morning Snack

Lunch
Afternoon Snack

Dinner
Evening Snack

Other

Two days before your illness, where did you eat breakfast*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for breakfast*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Two days before your illness, where did you eat the morning snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for the morning snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Two days before your illness, where did you eat the lunch*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for lunch*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Two days before your illness, where did you eat the afternoon snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for the afternoon snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Two days before your illness, where did you eat dinner?*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for dinner*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Two days before your illness, where did you eat the evening snack*

If meal was eaten at home, put "home". If meal was eaten at a food establishment, please also include the location.

Two days before your illness, what did you eat for the evening snack*

Please be as detailed as possible about foods consumed- include toppings, condiments, etc.

Other

What else did you eat? Please include where you ate it at and the approximately time you ate it*

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