Suspected Food Poisoning Report Form

Your Name:

Your Address:

Daytime Telephone:

Your E-mail address:

If you do not have an email address please leave the "Your E-mail address" box blank.

Which of these best describes your ethnic origin:

Are you still ill? Yes No

Symptoms (tick all that apply)
Diarrohea
Vomiting
Nausea
Abdominal pain
Fever
Headache
Muscular aches
Rash

When did the symptoms start? (Date and time)

How long did the symptoms last? (Please state number of hours or days)

Have you contacted your GP? Yes No

If so, have you submitted a stool sample? Yes No

Please provide your GP's name, address and telephone number

Do you work as or with any of the following?
Food handler
In a food environment (kitchen/waiting staff etc)
With children
With the elderly
With people with special needs

Please describe the suspected food:

When was the food eaten? (Please provide time and date)

Where was the food eaten?

Name/address of shop/restaurant/takeaway, etc. where food purchased (if applicable)

(Ready-to-eat foods) When purchased? (Please provide time and date)

Have you still got the food? Yes No

If yes, have you still got the packaging? Yes No