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.
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