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Mariam

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Suspected Food Poisoning (Children’s) questionnaire

|Personal Details |
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|Surname ………………………….. Forename ……………… Date of birth……/……./…….. |
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|Parents/Guardians Name………………………………………….. |
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|Home Address …………………………………………………………………………………………… |
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|…………………………………………………………………… Postcode………………………….. |
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|Home Telephone No………………….. Name and address of GP……………………………… |
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|Details of school/nursery attended |
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|Name of school or nursery………………………………… |
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|Address …………………………………………………….. |
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|………………………………………………………………. Telephone number………………………….. |

|Details of illness |
|What symptoms did your child have? |
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|Diarrhoea Vomiting Nausea Abdominal pain Fever Blood in stools |
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|Other please specify………………………………………………………………… |
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|Date symptoms started / / Time of first symptom am/pm |
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|How long did their symptoms last? Date symptoms ended / / |
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|Had they been excluded from school while they were ill? Yes No How many days? ..... |
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|Were they admitted to hospital? Yes No |
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|Had they been in hospital in the 2 weeks before being ill? Yes No |
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|Please give details of where admitted……………………………………………………………….. |
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|Household members |
|Please fill in the details for all people living in the same house as yourself. |
|Name |
|Date of birth |
|Occupation |
|Have they had similar symptoms? |
|When did they start? |
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|Contact with other people with potential food poisoning? |
|In the 14 days before their symptoms started had they been in contact with anyone with diarrhoea or vomiting? Yes No If yes, please give details. |
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|Name of contact |
|Age |
|Address if known |
|Telephone no if known |
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|Travel In the 14 days prior to their illness had they been abroad or travelled within the UK? |
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|Yes No If yes please complete following details: |
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|Country…………………………… Town or resort …………….. Where stayed ……………………… |
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|Dates stayed from ……../………/…….. to ………/……./… Tour operator ………………………… |
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|Was your stay: All inclusive Full board Half board Bed and breakfast |
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|Self catering Staying with friends/family |
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|If you wish to make a formal complaint about a premises abroad you can call Holiday Travelwatch |
|on 0845 017 9229 website- http://www.holidaytravelwatch.net/ |
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|Contact with animals In the 14 days before the start of their symptoms did they have any touching contact with animals or birds? Yes No If yes |
|please fill in following details; |
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|Pets at home ……………………………. |
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|Did they visit a farm or other animal establishment? Yes No Date of visit ……../……../…… |
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|Type animals …………………………….. |
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|Address of place visited …………………………………………………………….. |

|Consumption of dairy products In the 14 days before the start of their symptoms did they eat or drink any unpasteurised milk or milk products such as cheese? Yes |
|No |
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|If yes what was the product? ………………………………. |
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|Date when eaten ………/………/………. Where was it obtained from? ……………………………… |

|Water consumption /contact In the 14 days before the start of their symptoms did they consume water from ; |
|Well or borehole Yes No If yes where was this from …………………… |
|Bottled water Yes No |
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|Did they take part in any water sports or come in contact with any water other than in your home? |
|Yes No If yes please tick which apply; |
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|Swimming pool Freshwater Seawater Where was this? ………………………….. |

|Food consumption/social events |
|In the 14 days prior to the start of their symptoms did they eat any food that was from a take away outlet or restaurant? |
|Yes No If yes please give details; (if more space needed please continue on back of page) |
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|Date |
|Name and address of premises |
|Food eaten |
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Thank you for your help in completing this form. A member of the Environmental Health Team will review your answers and will contact you to discuss these further only if necessary.

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