Foodborne Illness Complaint Form
Please fill out as much of the information listed on this form as possible. If you have any questions please call us at 307-777-7007. If you are not sick and wish to make a complaint about the cleanliness, employee practices, and or sanitation of a food establishment, please visit the Wyoming Department of Agriculture Consumer Health Services website at: http://wyagric.state.wy.us/divisions/chs/contacts
Patient Information
First Name *
Last Name *
Age *
Gender *
Parent/Guardian Name (if child <18 years old)
Address
City *
State *
Telephone Number *
Alternate Phone Number
Occupation *
Illness Information
What date and time did you first start feeling ill?
MM
/
DD
/
YYYY
Time
:
Did you experience vomiting? *
What date and time did vomiting begin?
MM
/
DD
/
YYYY
Time
:
Did you expereince nausea?
Did you experience diarrhea? *
What date and time did diarrhea begin?
MM
/
DD
/
YYYY
Time
:
How many times did you have diarrhea in a 24 hour period?
Did you develop a fever?
Did you experience abdominal cramps?
Did you experience a headache?
Did you experience chills?
Did you experience weakness?
Did you experience fatigue?
Did you experience sweating?
Did you experience dizziness?
Did you experience numbness?
Did you experience tingling?
What other symptoms did you have?
Are you still sick? *
If no, when did you recover from your illness?
MM
/
DD
/
YYYY
Time
:
Medical Care Information
Did you visit a healthcare provider? *
If yes, what is the name of the healthcare provider?
Were you hospitalized?
If yes, what was the name of the hospital?
Was a stool specimen collected?
Stool specimen result
Establishment Information
Type of facility where the suspected food/beverage was bought or consumed *
If Other:
Name of facility *
Address
City *
State *
Details of Complaint
Date of exposure *
MM
/
DD
/
YYYY
Time of exposure *
Time
:
Number of people in your group while you were eating/drinking
Number of people in your group who became sick
Food/Beverage items suspected
For product complaints only:
Date item purchased
MM
/
DD
/
YYYY
Brand Name
Product Name
Manufacturer
Size and package type
Product codes
Expiration date
MM
/
DD
/
YYYY
72 Hour Food History
On the day before you became sick, what did you eat for breakfast?
Location
On the day before you became sick, what did you eat for lunch?
Location
On the day before you became sick, what did you eat for dinner?
Location
Two days before you became sick, what did you eat for breakfast?
Location
Two days before you became sick, what did you eat for lunch?
Location
Two days before you became sick, what did you eat for dinner?
Location
Three days before you became sick, what did you eat for breakfast?
Location
Three days before you became sick, what did you eat for lunch?
Location
Three days before you became sick, what did you eat for dinner?
Location
Contact Information for Others in Group (if applicable)
Name
Phone Number
Sick?
Name
Phone Number
Sick?
Name
Phone Number
Sick?
Any others, please list names, phone numbers, and if they were sick
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