Salmonella Class Action Information Form

 


Generated with MOOJ Proforms Basic Version 1.3
* Required information.
Full Name *
Phone Number *
Email Address *
From which store (including address) did you purchase the eggs? *
What was the brand name of the eggs purchased?
Can you provide proof of purchase (e.g. receipt)?
Approximately how long after consuming the eggs or egg product did you become ill?
What were your symptoms (e.g. fever, chills, diarrhea, abdominal cramps, headache, nausea, vomiting, weight loss, lack of energy, etc.)?
When and where did you first seek medical treatment?
Did you receive a diagnosis of salmonella poisoning? If so, from whom?
What medications, if any, were you prescribed?
From what dates (approx.) did you take the prescribed medication?
Have your symptoms resolved? If so, when did they resolve? If they are not resolved, what are your ongoing symptoms?
Which medical clinics and/or hospitals have you visited in relation to your illness?
What impact has your illness had on your enjoyment of life, including hobbies?
What impact has your illness had on your ability to complete housework (inside and outside)
Have you experienced a loss of income due to your illness?
Have you incurred any out-of-pocket expenses due to your illness?
mad4media user interface design