FOOD LIST - Tennessee



HEPATITIS A RESTAURANT PATRON QUESTIONNAIRE

Introduction: Hello, my name is ____ from the ______ Health Department. You may have heard about the hepatitis A outbreak in the area. As part of our disease investigation, I would like to ask you some questions about a restaurant you ate at recently. Your answers may be important in helping to find the cause of the illness.

GENERAL INFORMATION

Name _____________________________________ Phone Number: _____________________

Did you eat at Restaurant A during the month of August/Sept? YES NO

Please list dates and approximate times eaten at Restaurant A during August/Sept:

Note: Fill out a questionnaire for EACH DATE.

Date ______________ Meal: LUNCH DINNER BRUNCH Time ________________

Date______________ Meal: LUNCH DINNER BRUNCH Time ________________

Date______________ Meal: LUNCH DINNER BRUNCH Time ________________

How did you pay? CREDIT DEBIT CASH

Did you get carryout? YES NO DK

FOOD HISTORY FOR DATE _____________________

Do you remember the name of your server? YES NO DK If YES, list _________________

I’m going to ask you some general questions about what you ate at Restaurant A during your visit.

Did you eat an appetizer? YES NO DK

Did you eat soup? YES NO DK

Did you eat a salad as an entree? YES NO DK

Did you eat an item from the Daily Specials section? YES NO DK

Did you eat an item from the Steakhouse Favorites Section? YES NO DK

Did you eat on item from the Restaurant A Classics section? YES NO DK

Did you eat a SIDE ITEM (including a Side salad or side soup)

With any of the above sections? YES NO DK

Did you eat an item from the Specialties Section? YES NO DK

Did you eat an item from the Sandwiches/Burger section? YES NO DK

Did you eat side salad/cup soup with your Specialty item

Or sandwich? YES NO DK

Did you eat a Dessert? YES NO DK

--- RESTAURANT A MENU ITEMS BY SECTION ---

APPETIZERS

Spinach and Artichoke Dip: YES NO DK

Dip YES NO DK

Chips YES NO DK

Combo Appetizer: YES NO DK

Fried Cheese Wedges YES NO DK

Chicken Tenders YES NO DK

Loaded Potato Skins YES NO DK

Cheese YES NO DK

Bacon YES NO DK

S/C YES NO DK

Chives YES NO DK

Dipping Sauce YES NO DK

Shrimp Dip YES NO DK

Dip YES NO DK

Chips YES NO DK

Buffalo Tenders YES NO DK

Tenders YES NO DK

Ranch Sauce YES NO DK

Celery Sticks YES NO DK

Chipolte BBQ Tenders YES NO DK

Tenders YES NO DK

Chips YES NO DK

Chicken O’Tenders YES NO DK

Honey Mustard Dressing YES NO DK

Southwestern Chicken Quesadilla YES NO DK

Chicken YES NO DK

Onions YES NO DK

Peppers YES NO DK

Jalapenos YES NO DK

Cheese YES NO DK

Lettuce YES NO DK

S/C YES NO DK

Salsa YES NO DK

Cheese Wedges YES NO DK

Red pepper sauce YES NO DK

Loaded Potato Skins YES NO DK

Cheese YES NO DK

Bacon YES NO DK

S/C YES NO DK

Chives YES NO DK

Chips & Salsa: YES NO DK

Chips YES NO DK

Salsa YES NO DK

Onion Tanglers YES NO DK

Horseradish sauce YES NO DK

SOUPS YES NO DK

Loaded Potato Soup YES NO DK

Bacon YES NO DK

Cheese YES NO DK

Chives YES NO DK

Soup of the Day YES NO DK

List___________________________________________________________________

SALADS

Southern Fried Chicken Salad YES NO DK

Chicken YES NO DK

Cheese YES NO DK

Tomatoes YES NO DK

Mushrooms YES NO DK

Salad Greens YES NO DK

Dressing YES NO DK List______________________

Classic Caesar Salad YES NO DK

Lettuce YES NO DK

Parm Cheese YES NO DK

Croutons YES NO DK

Dressing YES NO DK List______________________

Chicken YES NO DK

Salmon YES NO DK

Cajun Chicken Salad YES NO DK

Chicken YES NO DK

Cheese YES NO DK

Tomatoes YES NO DK

Mushrooms YES NO DK

Salad greens YES NO DK

Dressing YES NO DK List______________________

Island Chicken Salad YES NO DK

Chicken tenders YES NO DK

Mandarin oranges YES NO DK

Romaine lettuce YES NO DK

Coconut YES NO DK

Almonds YES NO DK

Chives YES NO DK

Dressing YES NO DK List_____________________

Fresh Vegetable Steamer YES NO DK

Broccoli YES NO DK

Carrots YES NO DK

Squash YES NO DK

Rice pilaf YES NO DK

Dressing YES NO DK List___________________

DAILY SPECIALS Ask about side items on last page

Prime Rib YES NO DK

Baby Back Ribs Skillet YES NO DK

Ribs YES NO DK

BBQ Sauce YES NO DK

Fries YES NO DK

Coleslaw YES NO DK

Other/substitution YES NO DK List____________________

Steak tips Skillet YES NO DK

Steak tips YES NO DK

Onions YES NO DK

Mushrooms YES NO DK

Cheese YES NO DK

Rice YES NO DK

Vegetable Medley YES NO DK

Other/substitution YES NO DK List_____________________

STEAKHOUSE FAVORITES Ask about side items on last page

Sirloin YES NO DK

Prime Rib YES NO DK

Blackened Prime Rib YES NO DK

Horseradish sauce YES NO DK

3-Story Chopped Steak YES NO DK

Burgundy mushrooms YES NO DK

Onion tanglers topping YES NO DK

Smashed potatoes YES NO DK

Ribeye Steak YES NO DK

Filet Mignon YES NO DK

Burgundy mushroom toppings YES NO DK

Blue cheese topping YES NO DK

RESTAURANT A CLASSICS Ask about side items on last page

Steak Tips Monterey YES NO DK

Rice YES NO DK

Onions YES NO DK

Mushrooms YES NO DK

Cheese YES NO DK

Grilled salmon YES NO DK

Chipotle BBQ Salmon YES NO DK

Grilled tuna YES NO DK

Ginger sauce YES NO DK

Grilled/Fried Shrimp Dinner YES NO DK

Grilled shrimp YES NO DK

Rice YES NO DK

Drawn butter YES NO DK

Fried shrimp YES NO DK

Cocktail sauce YES NO DK

Blackened Rainbow Trout YES NO DK

Drawn butter YES NO DK

Steak & Shrimp Combo YES NO DK

Steak YES NO DK

Shrimp YES NO DK

Steak and Rib Combo YES NO DK

Steak YES NO DK

Ribs YES NO DK

BBQ sauce YES NO DK

Chicken Tenders YES NO DK

Dressing YES NO DK List______________________

SPECIALITES Ask about side items on last page

Baby Back Ribs YES NO DK

Fries YES NO DK

Cole slaw YES NO DK

Other YES NO DK List________________________

Fisherman’s Platter YES NO DK

Fish YES NO DK

Fries YES NO DK

Coleslaw YES NO DK

Tartar Sauce YES NO DK

Other YES NO DK List_______________________

Chicken Parmesan YES NO DK

Chicken YES NO DK

Marinara YES NO DK

Cheese YES NO DK

Linguini YES NO DK

Vegetable Medley YES NO DK

Other YES NO DK List _______________________

Chicken Teriyaki YES NO DK

Chicken YES NO DK

Teriyaki sauce YES NO DK

Pineapple ring YES NO DK

Rice YES NO DK

Vegetable medley YES NO DK

Other YES NO DK List _______________________

Grilled Chicken YES NO DK

Chicken YES NO DK

Smashed potatoes YES NO DK

Vegetable Medley YES NO DK

Other YES NO DK List_______________________

Cajun Chicken Pasta YES NO DK

Chicken YES NO DK

Linguini YES NO DK

Alfredo sauce YES NO DK

Parm cheese YES NO DK

Other YES NO DK List_________________________

Chicken Florentine YES NO DK

Chicken YES NO DK

Spinach etc. sauce YES NO DK

Linguini YES NO DK

Vegetable medley YES NO DK

SANDWICHES AND BURGERS Ask about side items on last page

Restaurant A club YES NO DK

Turkey YES NO DK

Bacon YES NO DK

Ham YES NO DK

Cheddar YES NO DK

Monterey Jack YES NO DK

Lettuce YES NO DK

Tomato YES NO DK

Wheat-berry bread YES NO DK

Dressing YES NO DK List_____________________

Southern Fired BLT YES NO DK

Chicken tenders YES NO DK

Wheat berry bread YES NO DK

Monterey jack YES NO DK

Bacon YES NO DK

Lettuce YES NO DK

Tomato YES NO DK

Cajun horseradish YES NO DK

Other dressing YES NO DK List_____________________

Three-cheese bacon burger YES NO DK

Burger YES NO DK

Cheddar YES NO DK

Swiss YES NO DK

Monterey jack YES NO DK

Bacon YES NO DK

Bun YES NO DK

Bacon and cheese chicken trio YES NO DK

Chicken YES NO DK

Cheddar YES NO DK

Swiss YES NO DK

Monterey jack YES NO DK

Bread YES NO DK

Buffalo Chicken Sandwich YES NO DK

Chicken YES NO DK

Buffalo sauce YES NO DK

Ranch dressing YES NO DK

Monterey jack YES NO DK

Bleu cheese YES NO DK

Bread/bun YES NO DK

Cajun/grilled Chicken Sandwich YES NO DK

Chicken YES NO DK

Lettuce YES NO DK

Tomato YES NO DK

Pickle YES NO DK

Onion YES NO DK

Dressing YES NO DK List______________________

Bread/bun YES NO DK

Country club chicken salad

Sandwich YES NO DK

Chicken YES NO DK

Pecans YES NO DK

Celery YES NO DK

Onions YES NO DK

Dressing YES NO DK List_____________________

Wheat-berry bread YES NO DK

Bacon YES NO DK

Lettuce YES NO DK

Tomato YES NO DK

Other YES NO DK List______________________

Fisherman’s TLC YES NO DK

Fish YES NO DK

Wheat-berry bread YES NO DK

Monterey jack YES NO DK

Lettuce YES NO DK

Tomato YES NO DK

Horseradish YES NO DK

Other YES NO DK List______________________

Roast Beef Stack YES NO DK

Roast beef YES NO DK

Bread/bun YES NO DK

Burgundy mushrooms YES NO DK

Monterey jack YES NO DK

Onion tangler toppings YES NO DK

Wheat-berry bread YES NO DK

Smashed potatoes YES NO DK

Fries YES NO DK

Other YES NO DK List____________________

DESSERTS

Caramel Pie YES NO DK

Whipped topping YES NO DK

Chocolate chips YES NO DK

Pecans YES NO DK

Caramel ice cream dream YES NO DK

Chocolate sauce YES NO DK

Caramel sauce YES NO DK

Whipped topping YES NO DK

Pecans YES NO DK

Chocolate chips YES NO DK

Chocolate Cake YES NO DK

Key Lime Pie YES NO DK

Whipped topping YES NO DK

SIDE ITEMS

Please ask all patrons specific side items that they ordered.

Side Caesar YES NO DK

Lettuce YES NO DK

Parm Cheese YES NO DK

Croutons YES NO DK

Dressing YES NO DK List______________________

House Salad YES NO DK

Lettuce YES NO DK

Cheese YES NO DK

Tomatoes YES NO DK

Mushrooms YES NO DK

Dressing YES NO DK List_______________________

Other YES NO DK List_______________________

Loaded Potato Soup YES NO DK

Bacon YES NO DK

Cheese YES NO DK

Chives YES NO DK

Soup of the Day YES NO DK List___________________

Other Side Items YES NO DK

Baked Potato YES NO DK

S/C YES NO DK

Butter YES NO DK

Other YES NO DK List_____________________

Smashed Potatoes YES NO DK

French Fries YES NO DK

Rice Pilaf YES NO DK

Vegetable Medley YES NO DK

Steamed Broccoli YES NO DK

Cole Slaw YES NO DK

Rolls YES NO DK

KIDS MENU

Hamburger and Fries YES NO DK

Other/substitution YES NO DK List_____________________

Chicken O’Tenders and Fries YES NO DK

Other/substitution YES NO DK List_____________________

3oz. Steak and Fries YES NO DK

Other/substitution YES NO DK List_____________________

Macaroni and Cheese YES NO DK

Other/substitution YES NO DK List_____________________

SUNDAY BRUNCH

O’Charley’s Prime Rib YES NO DK

Steak and Eggs YES NO DK

Potatoes YES NO DK

Toast YES NO DK

Cajun Chicken Omelette YES NO DK

Chicken tenders YES NO DK

Cheese YES NO DK

Peppers YES NO DK

Onions YES NO DK

Potatoes YES NO DK

Toast YES NO DK

O’Charley’s Ultimate Omelette YES NO DK

Ham YES NO DK

Peppers YES NO DK

Onions YES NO DK

Mushrooms YES NO DK

Tomatoes YES NO DK

Cheese YES NO DK

Potatoes YES NO DK

Toast YES NO DK

Ham & Cheese Omelette YES NO DK

Ham YES NO DK

Cheese YES NO DK

Potatoes YES NO DK

Toast YES NO DK

Spanish Omelette YES NO DK

Cheese YES NO DK

Salsa YES NO DK

Sour cream YES NO DK

Potatoes YES NO DK

Toast YES NO DK

Eggs & Bacon YES NO DK

Eggs & Sausage YES NO DK

Eggs only YES NO DK

Potatoes YES NO DK

Toast YES NO DK

Bavarian Waffle YES NO DK

Powdered sugar YES NO DK

Butter YES NO DK

Syrup YES NO DK

Strawberries YES NO DK

Whipped topping YES NO DK

Pecans YES NO DK

Muffin Basket YES NO DK

BEVERAGES

Do you recall what you had to drink with your meal? YES NO DK

Please list beverages: ____________________________________________________________

Did any of your beverages include ice? YES NO DK

If YES, please list beverages with ice__________________________________________

Did your beverage include a garnish? YES NO DK

If YES, please list garnish (e.g., lemon, lime, orange) ____________________________

Did you order a drink from the bar? YES NO DK

If YES, did it include a garnish? YES NO DK

If YES, please list garnish___________________________________________________

OTHER

Did you share food items with others at your table? YES NO DK

If YES, with whom? ________________________________________________

List items__________________________________________________________

Did you sample items off another’s plate at your table? YES NO DK

If YES, whose? ____________________________________________________

List items__________________________________________________________

Did you use the restroom facilities at the restaurant

when you dined during the week in question? YES NO DK

CONTROLS

Please list others with whom you dined during this week who have not become ill and (if known) their contact information:

NAME ADDRESS PHONE # RELATIONSHIP

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

-----------------------

Date__________________________

Circle one: CASE CONTROL Interviewer_____________________

Skip to the Menu list on next page and answer the questions about the specific food item ordered from each category. Do not forget to ask about the side items on the last page.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download