□ Abdominal Cramps
□ Loss of Appetite
2. Please mark any of the following symptoms that you have had SINCE ATTENDING the meeting on July 19,1996.
□ NONE *(IF NONE, PLEASE MARK NONE AND GO TO QUESTION #10)
Type of Diarrhea:
□ Watery Diarrhea
□ Bloody Diarrhea
Other Symptoms: _
3. What day did your symptoms begin?
4. What time did your symptoms begin?
5. How long did your symptoms last?
6. Did you seek medical care for your symptoms? If YES, name of doctor?_
7. Were you hospitalized for your symptoms?
8. Did you provide a stool sample for testing? Results of the test?_
9. Did any family/household members who did not attend the meeting experience similar symptoms following your illness?
10. Have you recently had any diarrhea, vomiting, or other symptoms before the meeting?
11. Did you eat any food(s) or drink any beverage(s) at the meeting held on July 19,1996 at Establishment A?
□ YES □ NO If YES, what time did you eat? TIME:_:_ □ AM □ PM
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