Oswego
Questionnaire for Church Supper - Oswego
Code
Name
Age:
###
Sex:
Male
Female
Unknown
Select one
Ill?
Yes
No
Select one
Time Supper
mm-dd-yyyy hh:mm:ss ampm
Date Onset
mm-dd-yyyy hh:mm:ss ampm
Food History (Mark Yes or No):
Beverages
Milk:
Yes
No
Select one
Coffee:
Yes
No
Select one
Water:
Yes
No
Select one
Food Items
Baked Ham:
Yes
No
Select one
Spinach:
Yes
No
Select one
Mashed Potatoes:
Yes
No
Select one
Cabbage Salad:
Yes
No
Select one
Jello:
Yes
No
Select one
Rolls:
Yes
No
Select one
BrownBread:
Yes
No
Select one
FruitSalad:
Yes
No
Select one
Desserts
Cakes:
Yes
No
Select one
Vanilla Ice Cream
Yes
No
Select one
Chocolate Ice Cream:
Yes
No
Select one
Record Unique Identifier
Record is completed