Quantcast Figure 1-9. Case History Questionnaire

 

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CHAPTER 1, FOOD SAFETY
Figure 1-9.
Case History Questionnaire
Name:
Rank/Rate:
SSN:
Duty Station:
Work Phone:
Home Phone:
Age:
Sex:
Home Address:
Other Information:
Signs and Symptoms (check appropriate items)
o
o
o Abdominal Cramps
o Burning Sensations
Numbness
Headache
o
o
o Diarrhea
(mouth)
Dizziness
Chills
o Metallic Taste
o
o
o Bloody Diarrhea
Double Vision
Myalgia
o Excessive
o
o
o Mucus Diarrhea
Blurred Vision
Edema
o
o
o Watery Diarrhea
Salivation
Dysphagia
Jaundice
o Nausea
o
o
_____ # of Bowel
Dysphoria
Anorexia
o Vomiting
o
o
Movements Per Day
Delirium
Rash
o Fever _______TempF
o Flushing
o
o
Paralysis
Weakness
o Itching
o
o
o Duration of Fever
Coma
Dehydration
o Prostration
o Cyanosis
Other Symptoms:
Treatment:
Time and Date
Duration:
Severity:
of Onset:
mild - severe
1234
Physician Consulted:
Address:
Phone:
Hospital:
Address:
Phone:
Specimens
Time/Date of Collection:
Laboratory Results:
Obtained:
Remarks and Diagnosis:
o Ill
o Well
133


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