Yes If yes, Name of hospital: ♦ Were you admitted to No hospital as a result of your ♦ Date of admission: illness (not including stay in Don’t recall Date of discharge: the emergency room)? Unknown discharge date For iPHIS data entry if the case is hospitalized enter information under Interventions. → – Were you prescribed Yes If yes, Medication: antibiotics or medication No Start date: End date: for your illness? Don’t recall of administration: Dosage: Did you take Yes counter medication? No Don’t recall Treatment information can be entered in iPHIS under Cases > Case > Rx/Treatments>Treatment as per current iPHIS User Guide Date of Onset, Age and Gender Complete this section if submission of pages 5-7 and 11 to Public Health Ontario is required Date of Onset: Age: Gender: Response Details Preliminary Questions No Yes Unsure Do you have any idea how you became sick? Were you on any specific diet(s) in the 1-12 days prior to the onset of your illness (e.g., vegetarian, vegan, gluten-free, kosher, halal, etc.)?
♦ Were you admitted to hospital as a result of your illness (not including stay in the emergency room)? Yes No Don’t recall If yes, Name of hospital: ♦ Date of admission: Date of discharge: Unknown discharge date → For iPHIS data entry – if the case is hospitalized enter information under Interventions. Were you prescribed antibiotics or medication for your illness? Yes No Don’t recall If yes, Medication: Start date: End date: of administration: Dosage: Did you take medication? Yes No Don’t recall Treatment information can be entered in iPHIS under Cases > Case > Rx/Treatments>Treatment as per current iPHIS User Guide Date of Onset, Age and Gender Complete this section if submission of pages 5-7 and 11 to Public Health Ontario is required Date of Onset: Age: Gender: Preliminary Questions Response Details Yes No Unsure Do you have any idea how you became sick? Were you on any specific diet(s) in the 1-12 days prior to the onset of your illness (e.g., vegetarian, vegan, gluten-free, kosher, halal, etc.)? counter
Cryptosporidiosis%20Investigation%20Tool.docx