| Full Name * |
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| Phone Number * |
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| Email Address * |
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| From which store (including address) did you purchase the eggs? * |
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| What was the brand name of the eggs purchased? |
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| Can you provide proof of purchase (e.g. receipt)? |
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| Approximately how long after consuming the eggs or egg product did you become ill? |
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| What were your symptoms (e.g. fever, chills, diarrhea, abdominal cramps, headache, nausea, vomiting, weight loss, lack of energy, etc.)? |
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| When and where did you first seek medical treatment? |
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| Did you receive a diagnosis of salmonella poisoning? If so, from whom? |
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| What medications, if any, were you prescribed? |
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| From what dates (approx.) did you take the prescribed medication? |
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| Have your symptoms resolved? If so, when did they resolve? If they are not resolved, what are your ongoing symptoms? |
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| Which medical clinics and/or hospitals have you visited in relation to your illness? |
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| What impact has your illness had on your enjoyment of life, including hobbies? |
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| What impact has your illness had on your ability to complete housework (inside and outside) |
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| Have you experienced a loss of income due to your illness? |
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| Have you incurred any out-of-pocket expenses due to your illness? |
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