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Environmental Health

200 W. Front St. Bloomington, IL 61701

(309) 888-5482

Foodborne & Waterborne Illness Investigation Questionnaire

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.

Citizen Information

Full Name

Your Address

Date of Birth

Date Picker

Incident Information

Did anyone else in your party become ill?

Date suspected meal consumed:

Date Picker

Onset of symptoms date:

Date Picker

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?

During 24 hours (1 day) before onset of symptoms:

Dinner Date:

Date Picker

Lunch Date:

Date Picker

Breakfast Date:

Date Picker

During 48 hours (2 days) before onset of symptoms:

Dinner Date:

Date Picker

Lunch Date:

Date Picker

Breakfast Date:

Date Picker

During 72 hours (3 days) before onset of symptoms:

Dinner Date:

Date Picker

Lunch Date:

Date Picker

Breakfast Date:

Date Picker

For further information, please contact Personal Health Services by calling (309) 888-5435, option 3.