Houston Health Department

Foodborne Complaint Form

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  Name of the food establishment ...
 
. 
  Address of the food establishment ...
 
  
Providing information in this dark gray box is optional
Your name:
Your phone:
Your e-mail:
  
. 
  Date of meal ...
 
. 
  Time of meal (include AM or PM) ...
 
. 
  How many people became ill?
 
. 
  How many were in your party?
 
. 
   Was this meal a carry-out meal? (food to go, from taco stand, etc.)
YES
... NO
. 
   Was this a catered event?
YES
... NO
. 

If more than two persons became ill, please call 832.393.5100 immediately after completing this form.

. 
   Was a doctor visited?
YES
... NO
. 
  Doctor's name:
 
. 
  Doctor's phone number:
 
. 
   Was a stool specimen submitted?
YES
... NO
. 
  Date of stool sample ...
 
. 
  Time of stool sample (include AM or PM) ...
 
. 
  Food items consumed ...
 
. 
   Did you notice anything unusual about the food?
YES
... NO
. 
  Time of onset (include AM or PM) ...
 
. 
  Date of onset ...
 
. 
  Symptoms (check all tht apply) ...
Nausea
Vomiting
Diarrhea
Chills / Sweats
Headache
Cramps
Fever
Dizziness
Other
What other?
.
 
   Were beverages consumeed?
YES
... NO
. 
  What beverage(s)?