Environmental Engineering Reference
In-Depth Information
Please answer the questions below to the best of your ability. This in-
formation is desired by the health department to determine the cause of the recent
sickness and to prevent its recurrence. Leave this sheet, after you have completed
it, at the desk on your way out. (If mailed, enclose self-addressed and stamped
envelope and request return of completed questionnarie as soon as possible.)
1.
Check any of the following conditions that you have had:
Nausea
Fever
Sore throat
Cough
Chills
Weakness
Cramps
Other
Vomiting
Diarrhea
Thirst
Constipation
Stomach ache
Sweating
Headache
Dizziness
Paralysis
Pain in chest
Laryngitis
Bloody stool
2.
Were you ill? ............ Yes .............No.
3.
4.
5.
If ill, first became sick on: Date.............Hour............. A.M. / P.M.
How long did the sickness last ? ..............................................................................
Check below ( ) the food eaten at each meal and (
×
) the food not eaten.
Answer even though you may not have been ill.
Meal
Breakfast
Tuesday
Wednesday
Thursday
Apple juice,
Corn flakes, oatmeal,
fried eggs, bread,
coffee, milk, water
Orange, pancakes,
wheaties, syrup,
coffee, milk,
water
Grapefruit, Wheatina,
shredded wheat,
boiled egg, coffee,
milk, water
Lunch
Baked salmon,
creamed potatoes,
corn, apple pie,
lemonade, water
Roast pork,
baked potatoes,
peas, rice pudding,
milk, water,
chef salad
Swiss steak,
home fried potatoes,
turnips, spinach,
chocolate pudding,
orange drink, milk,
water
Dinner
Gravy,
hamburger steak,
mashed potatoes,
salmon salad,
cookies, pears,
cocoa, water
Roast veal
rice, beets, peas,
jello,
coffee, water
Fruit cup,
meatballs, spaghetti,
string beans,
pickled beets,
sliced pineapple,
tea, coffee, milk
6.
Did you eat food or drink water outside? ................ If so, where and when?
..................................................................................................................................
7.
8.
Name................................................ Tel........................ Age ............ Sex...............
Remarks (Physician's name, hospital)......................................................................
.................................................................. Investigator ...........................................
FIGURE 1.5
Questionnaire for illness from food, milk, or water.
