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
Your answer
Last Name
Your answer
Age
Your answer
Gender
Parent/Guardian Name (if child <18 years old)
Your answer
Address
Your answer
City
Your answer
State
Your answer
Telephone Number
Your answer
Alternate Phone Number
Your answer
Occupation
Your answer
Illness Information
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?
Your answer
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?
Your answer
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?
Your answer
Were you hospitalized?
If yes, what was the name of the hospital?
Your answer
Was a stool specimen collected?
Stool specimen result
Your answer
Establishment Information
Type of facility where the suspected food/beverage was bought or consumed
If Other:
Your answer
Name of facility
Your answer
Address
Your answer
City
Your answer
State
Your answer
Details of Complaint
Date of exposure
MM
/
DD
/
YYYY
Time of exposure
Time
:
Number of people in your group while you were eating/drinking
Your answer
Number of people in your group who became sick
Your answer
Food/Beverage items suspected
Your answer
For product complaints only:
Date item purchased
MM
/
DD
/
YYYY
Brand Name
Your answer
Product Name
Your answer
Manufacturer
Your answer
Size and package type
Your answer
Product codes
Your answer
Expiration date
MM
/
DD
/
YYYY
72 Hour Food History
On the day before you became sick, what did you eat for breakfast?
Your answer
Location
Your answer
On the day before you became sick, what did you eat for lunch?
Your answer
Location
Your answer
On the day before you became sick, what did you eat for dinner?
Your answer
Location
Your answer
Two days before you became sick, what did you eat for breakfast?
Your answer
Location
Your answer
Two days before you became sick, what did you eat for lunch?
Your answer
Location
Your answer
Two days before you became sick, what did you eat for dinner?
Your answer
Location
Your answer
Three days before you became sick, what did you eat for breakfast?
Your answer
Location
Your answer
Three days before you became sick, what did you eat for lunch?
Your answer
Location
Your answer
Three days before you became sick, what did you eat for dinner?
Your answer
Location
Your answer
Contact Information for Others in Group (if applicable)
Name
Your answer
Phone Number
Your answer
Sick?
Name
Your answer
Phone Number
Your answer
Sick?
Name
Your answer
Phone Number
Your answer
Sick?
Any others, please list names, phone numbers, and if they were sick
Your answer
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