139

FOOD POISONING INVESTIGATION FORM

(PERSONAL DETAILS)
Please complete in BLOCK CAPITALS

Name: Room Number (if applicable):

Dates of visit:

Address: Tel – Home:

Tel – Work:

Postcode: Tel – Mobile:

When and where can you usually be contacted?

Occupation:

Have you visited your GP or been taken to hospital?

Have you had a specimen taken?

Have you been abroad or on any other holiday in the past calendar month? If yes, where and when?

Have you been in contact with any pets or other animals in the past two weeks?

Please list any further details you may feel are relevant to the illness:
 140

FOOD POISONING INVESTIGATION FORM

(DIETARY DETAILS)
Please describe all meals eaten on the following days:

Day symptoms started: Breakfast: Location:

Date:

Snacks: Time:
Lunch: Location: Dinner: Location:

Time:: Time::

Day before symptoms started: Breakfast: Location:

Date:

Snacks: Time:
Lunch: Location: Dinner: Location:

Time:: Time::

Two days prior: Breakfast: Location:

Date:

Snacks: Time:
Lunch: Location: Dinner: Location:

Time:: Time::

Three days prior: Breakfast: Location:

Date:

Snacks: Time:
Lunch: Location: Dinner: Location:

Time:: Time::
141

FOOD POISONING INVESTIGATION FORM

(SYMPTOM DETAILS)
Please describe the duration, onset and severity of the applicable symptoms below:

Symptoms Time and Date of Onset How long did Symptoms last

Headaches

Rash

Nausea

Vomiting

Stomach cramps

Diarrhoea

Bloody diarrhoea

Dizziness

High temperature

Other symptoms

Have you been in contact with anyone else that you know has had similar symptoms recently? If Yes, please give
details including date of this contact: