Figure 1-9. Case History Questionnaire (cont)

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:

Day Before Illness

Breakfast

Lunch

Supper

Hour:

Place:

Hour:

Place:

Hour:

Place:

Food Items:

Two Days Before Illness

Breakfast

Lunch

Supper

Hour:

Place:

Hour:

Place:

Hour:

Place:

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:

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