Quantcast Figure 1-9. Case History Questionnaire (cont)

 

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MANUAL OF NAVAL PREVENTIVE MEDICINE
Figure 1-9.
Case History Questionnaire (con't)
Food History for Previous 72 Hours or Other Specified Time:
Day of Illness
Breakfast
Lunch
Supper
Hour:
Place:
Hour:
Place:
Hour:
Place:
Food Items:
Food Items:
Food Items:
Day Before Illness
Breakfast
Lunch
Supper
Hour:
Place:
Hour:
Place:
Hour:
Place:
Food Items:
Food Items:
Food Items:
Two Days Before Illness
Breakfast
Lunch
Supper
Hour:
Place:
Hour:
Place:
Hour:
Place:
Food Items:
Food Items:
Food Items:
Snacks (items, time and place)
History of Eating Suspect Food
Food:
Source:
Address:
Common Event and Names and Addresses of others at event:
Recent Travel
(locations):
Contacts With Known Cases Before Illness:
Contact After Illness:
Other Conditions (Housing Condition, Crowding, Water/Milk Supply, Excreta
Disposal, Shellfish):
Additional Remarks:
Investigator:
Date:
134


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