The Health Department is investigating the reports of illness that occurred following the

_______Mother’s Day Dinner Party at Miami-Dade’s Deli________ on _May 29, 2021_________.

(event) (date)

It is important that anyone who attended fill out a questionnaire, even if you did not get sick.

Last name _____Saunders______________________ First name _______John_____________________

Age____48_________
Home phone number: (_786_)__897-2060______ Sex: Male / Female (circle one)
Did you eat at this event? YES NO

Please circle YES for any food item you ate at the event and circle NO for each item that you did not eat.
All items must be answered either YES or NO.

1. Beef YES NO 7. Letuce YES NO

2. Pork YES NO 8. Brocoli YES NO
3. Chicken YES NO 9. Tomatoes YES NO
4. Fish YES NO 10. Banana YES NO
5. Eggs YES NO 11. Nuts YES NO
6. Milk YES NO 12. Proons YES NO

Did you have any drinks on ice? YES NO

Did you have any soft drinks on ice? YES NO
Did you have any alcoholic drinks on ice? YES NO (Number of drinks: 20
Did you have any non-iced alcoholic drinks? YES NO (Number of drinks:______)

Was anyone in your household ill with diarrhea or vomiting in the week preceding the event?
YES NO (If yes, who and when? My Wife, after the event)

Have you become ill since attending the event? YES NO

If yes, please circle YES or NO for each of the following symptoms:

Diarrhea YES NO If yes, # of stools on the worst day: _8_ Any blood in your stool? YES / NO
Stomach cramps YES NO
Nausea YES NO
Vomiting YES NO
Fever YES NO If yes, what was your highest temperature? ____________
Headache YES NO
Body aches YES NO
Chills YES NO

Date illness began: 05/31/2021 Time illness began: 8:30 AM / PM

Are you still having symptoms? YES NO If no, when did symptoms end? ________ (date & time)
Did you take any medicine for this illness? YES NO If yes, what medicine? Imodium and Peptobismol
Did you go to the doctor or ER for this illness? YES NO If yes, name of doctor or ER: Roberto Cuello MD.
Were you admitted to the hospital? YES NO If yes, name of hospital: Kendall Regional Hospital