Waitrose UAE & Partners | Grocery Delivery in Dubai & Abu Dhabi

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Branch name^*

Let us know your feedback^*

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FOOD BORNE ILLNESS QUESTIONNAIRETo be filled in cases of suspected Food Borne Illness / Food Poisoning claims.

Date of birth^*

Age^*

Do you have any pet animal ?^*

GP name & address

Occupational details

Clinical Details

What symptoms do you have?

Diarrhoea

Abdominal pain

Vomiting

Nausea

Fever

Blood in stool

Others

On what date did your symptom start?^*

Time of first symptom

Do you still have these symptoms ?^*

If No, date your symptoms ended^*

Did you see a GP?

Were you admitted in hospital?

Have you submitted a fecal / vomit sample?^*

If Yes, date submitted^*

Whom did you submit the sample to ?^*

Result if known

Household memberskindly fill in the below details for all people living in the same house:

Add More

Name

Date of birth

Relationship

Occupation

Have they had similar symptom?

If yes, when did it start?

In the 14 days before the start of the symptom

Have you been in the company of others suffering from diarrhoea/ similar symptom?

Did you travel abroad?

Did you visit an animal / bird farm ?

Did you partake in any water activity like swimming, jaccuzzi?

Did you attend any social events like parties, receptions, trainings, restaurant ?

Did you drink any untreated water / tap water ?

Food History Please fill in the food history as much as possible, to identify a possible source of infection

On the day your symptoms started

Meal

Date of cooking

Details of food consumed