Foodnet Case Report - Tennessee Department Of Health Page 2
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1
2S
H
YMPTOM
ISTORY
Date/Time of Illness Onset: ____/____/_______ ____:____ □ AM □ PM
First Symptom: ________________________
□ Abdominal cramps
□ Anorexia
□ Backache
□ Bloody diarrhea
□ Bullae
Symptoms:
(Check all
□ Cellulitis
□ Chills
□ Constipation
□ Diarrhea
□ Fatigue
that apply)
□ Fever (Max)
__
°F
□ Headache
□ Muscle aches
□ Nausea
□ Shock
□ Vomiting
□ Weight loss
□ Reactive Arthritis
□ Other ________________________
I
Y
D
,
I
Y
V
,
O
I
I
F
ES TO
IARRHEA
F
ES TO
OMITING
THER
LLNESS
NFORMATION
Date/Time of Diarrhea Onset:
Date/Time of Vomiting Onset:
Date/Time of Recovery:
____/____/_______ ___:___ □ AM □ PM
____/____/_______ ___:___ □ AM □ PM
____/____/_______ ___:___ □ AM □ PM
Maximum number of stools in a
Maximum number of vomiting
Duration of Illness:
______ □ Minutes □ Hours □ Days
24-hour period: ______
episodes in a 24-hour period: ______
Are you still experiencing symptoms?
Are you still experiencing symptoms?
If known, Date/Time of Exposure:
____/____/_______ ___:___ □ AM □ PM
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
Location:
If no longer experiencing symptoms,
If no longer experiencing symptoms,
_____________________________________
how long did they last?:
how long did they last?:
_____________________________________
______ □ Minutes □ Hours □ Days
______ □ Minutes □ Hours □ Days
_____________________________________
T
H
RAVEL
ISTORY
□ Yes
□ No
□ Unknown
Did patient travel prior to onset of illness?
□ Domestic
__________________
□ Airplane
□ Bus
□ Car
Type:
Destination 1:
Mode of travel:
□ International
__________________
□ Cruise
□ Ship
□ Train
Date of Arrival:
____/____/_______
Date of Departure:
____/____/_______
□ Domestic
__________________
□ Airplane
□ Bus
□ Car
Type:
Destination 1:
Mode of travel:
□ International
__________________
□ Cruise
□ Ship
□ Train
Date of Arrival:
____/____/_______
Date of Departure:
____/____/_______
If more than 2 destinations,
please specify here:
R
C
ELATED
ASES
□ Yes
□ Yes
Does the patient know of
If yes, did the health department collect
□ No
□ No
any similarly ill persons
contact information about other similarly
□ Unknown
□ Unknown
(with diarrhea)?:
ill persons and investigate further?:
□ Yes, household
□ Yes, outbreak
□ No, sporadic
□ Unknown
Are there any other cases related to this one?:
Provide names, onset dates, contact information and any other details for similarly ill persons or related cases:
F
N
OOD
ET
□ Yes
□ No
□ Unknown
FoodNet Case?:
C
-C
I
ASE
ONTROL
NFORMATION
□ Yes
□ No
□ Unknown
T
H
I
In a case-control study?
RANSFER
OSPITAL
NFORMATION
Was the patient transferred
O
I
UTBREAK
NFORMATION
from one hospital to another?: □ Yes
□ No
□ Unknown
Type of outbreak:
□ Animal contact
□ Other
If yes, specify name of the hospital to which the patient
was transferred: ____________________________________
□ Environmental contamination
□ Person-to-person
other than food/water
S
H
ECOND
OSPITALIZATION
Was there a second
□ Foodborne
□ Waterborne
□ Yes
□ No
□ Unknown
hospitalization?:
□ Indeterminate
□ Unknown
If yes, Hospital Name:
_______________________________
CDC EFORS/NORS number?
___________________________
Admission Date:
____/____/_______
A
I
UDIT
NFORMATION
Discharge Date:
____/____/_______
Was the case found
I
MMIGRATION
□ Yes
□ No
□ Unknown
during an audit*?
Did patient immigrate to
the US within 7 days of
*Our FoodNet hospital visit constitutes an audit.*
□ Yes
□ No
□ Unknown
specimen collection?:
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