200 W. Front St. Bloomington, IL 61701
(309) 888-5482
Individuals are required to provide information about their illness and eating/drinking habits as part of a foodborne illness investigation. Please answer the following questions to the best of your knowledge.
Full Name
Your Address
Date of Birth
Did anyone else in your party become ill?
Date suspected meal consumed:
Onset of symptoms date:
Which of the following symptoms did you experience? (Check all that apply)
Did you call or see a physician?
Has a stool culture been done?
Dinner Date:
Lunch Date:
Breakfast Date:
For further information, please contact Personal Health Services by calling (309) 888-5435, option 3.