EColi
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
E. Coli
O157:H7 Food History Questionnaire
Centers for Disease Control and Prevention
_______________________________________________________________________________________________________
Case ID
Date of Interview
mm-dd-yyyy
Enter date between 01-15-2011 and 12-31-2012
All data contained herein are fictional
Demographic Information
First Name
Last Name
Sex
A-Ambiguous
F-Female
M-Male
N-Not applicable
O-Other
U-Unknown
Select one
DOB
mm-dd-yyyy
Age
Ethnicity Group
2135:2-Hispanic or Latino
2186:5-Not Hispanic or Latino
Select one
Race:
White
Native Hawaiian/Other Pacific Islander
Unknown/Other
Black
American Indian/Alaskan Native
Asian
Multiracial
Address
State
Latitude:
###.##############
Longitude
####.##############
Occupation
Email Address
Home Phone
###-###-####
Symptoms and Illness
Was the patient ill?
Yes
No
Select one
Symptom Onset Date
mm-dd-yyyy
Enter date between 01-15-2011 and 12-31-2012
Onset Week
(Read Only)
Duration of Symptoms
Headache
Fever
Vomiting
Bloody diarrhea
Non-bloody diarrhea
Poor feeding
Chills
Irritable
Nausea
Abdominal cramps
Highest fever temp
###.#
Enter number between 80 and 110
If patient had diarrhea, how many loose stools per day?
1-3 per day
4-6 per day
7-10 per day
10+ per day
Select one
Was the patient ill enough to require a doctor visit?
Yes
No
Select one
Doctor visit date:
mm-dd-yyyy
Enter date between 01-15-2011 and 01-15-2012
Was the patient hospitalized?
Yes
No
Select one
Hospital admission date:
mm-dd-yyyy
Enter date between 01-15-2011 and 01-15-2012
Was the patient treated with antibiotics?
Yes
No
Select one
Did the patient die?
Yes
No
Select one
Date of death:
mm-dd-yyyy
Enter date between 01-15-2011 and 12-31-2012
E. Coli
O157:H7 Food History Questionnaire
Foods Eaten
Fresh celery
Grapes
Blueberries
Breast milk
Skim milk
Cheddar cheese
Peaches
American cheese
Strawberries
Orange juice
Apple juice
Fresh tomatoes
Beef jerkey
Sour cream
Vienna sausages
2% milk
Ice cream
Turkey
Whole milk
Raw carrots
Bean sprouts
Butter
Cooked bacon
Where did you buy meat, vegetables or other groceries that were eaten in the 10 days before the patient got sick?
Lab Testing and Results
Stool sample submitted for enteric culture?
Yes
No
Select one
Collection date:
mm-dd-yyyy
Enter date between 01-15-2011 and 12-31-2012
O157:H7 isolated?
Yes
No
Select one
Lab:
Lab results:
Record Unique Identifier
Record is completed