Toddler QuestionnaireTemplate



INFANT / TODDLER SHOTGUN (2008-xxx) Phone _________________

Age _____ Sex ρ M ρ F Interviewee ρ self ρ parent ρ spouse ρ ______ Interviewed by ______ on ______

First positive specimen collected __/___/____ PHL ID ________ Source ρ stool ρ urine ρ blood ρ ______

Onset of first symptoms (m/d/y) __/___/____ Time of first onset ___am ρ noon ___pm ρ midnight

Onset of first vomiting or diarrhea (m/d/y) __/__/____ Time of first V or D ___am ρ noon ___pm ρ midnight

| Y ? N |Lead-In QUESTIONS [[i]] |

|A ρ ρ ρ |Did your child spend any time outside of your home state in the 7 days before your child got sick? |

| |If yes, please specify where you traveled and the dates of your trip _________________. |

|B ρ ρ ρ |Do you make a point to select mostly organic products when you shop for your child? |

|C ρ ρ ρ |Is your child a vegetarian or a vegan? |

|D ρ ρ ρ |Did your child eat or drink products from any of the following brands of toddler food in the week prior to illness? |

| |E ρ Earth’s Best Fρ Gerber Graduates G ρGerber Organic H ρBeechnut I ρOther _______ |

|J ρ ρ ρ |Did your child eat at any restaurants or places outside your home in the week prior to becoming ill? |

| |If yes, please specify. |

You said that you ate at some restaurants [and fast food places]. Let me run through a list of some popular national chains to see if you remember eating there during that time.

|[[ii]] Y ? N |FAST FOOD CHAINS |[[iii]] Y ? N |CHAIN RESTAURANTS |[[iv]] Y ? N |RESTAURANT GENRES |

|A ρ ρ ρ |A & W |A ρ ρ ρ |Applebee’s |A ρ ρ ρ |Chinese |

|B ρ ρ ρ |Arby’s |B ρ ρ ρ |Chili’s |B ρ ρ ρ |Vietnamese |

|C ρ ρ ρ |Baskin-Robbins |C ρ ρ ρ |Chuck E Cheese |C ρ ρ ρ |Thai |

|D ρ ρ ρ |Boston Market |D ρ ρ ρ |Country Kitchen |D ρ ρ ρ |Japanese |

|E ρ ρ ρ |Burger King |E ρ ρ ρ |Denny’s |E ρ ρ ρ |Indian/South Asian |

|F ρ ρ ρ |Carl’s Jr. |F ρ ρ ρ |Friendly’s |F ρ ρ ρ |other Asian |

|G ρ ρ ρ |Dairy Queen |G ρ ρ ρ |Hardee’s |G ρ ρ ρ |Mexican |

|H ρ ρ ρ |Del Taco |H ρ ρ ρ |HomeTown Buffet |H ρ ρ ρ |other Latin American |

|I ρ ρ ρ |Domino’s |I ρ ρ ρ |IHOP |I ρ ρ ρ |pizzeria |

|J ρ ρ ρ |Dunkin Donuts |J ρ ρ ρ |Olive Garden |J ρ ρ ρ |Italian |

|K ρ ρ ρ |Jack-in-the-Box |K ρ ρ ρ |Red Lobster |K ρ ρ ρ |French/Spanish/European |

|L ρ ρ ρ |KFC |L ρ ρ ρ |Ruby Tuesday’s |L ρ ρ ρ |Cuban/Caribbean |

|M ρ ρ ρ |Krystal |M ρ ρ ρ |Sbarro |M ρ ρ ρ |Greek |

|N ρ ρ ρ |McDonald’s |N ρ ρ ρ |Shari’s |N ρ ρ ρ |Middle Eastern/Arabic |

|O ρ ρ ρ |Panda Express |O ρ ρ ρ |Sizzler |O ρ ρ ρ |Other “international” |

|P ρ ρ ρ |Papa Murphy’s |P ρ ρ ρ |T.G.I. Fridays |P ρ ρ ρ |vegetarian or vegan |

|Q ρ ρ ρ |Pizza Hut |Q ρ ρ ρ |Waffle House |Q ρ ρ ρ |barbeque |

|R ρ ρ ρ |Quizno’s |R ρ ρ ρ |Starbucks |R ρ ρ ρ |steakhouse or grill |

|S ρ ρ ρ |Round Table | | |S ρ ρ ρ |"family" restaurant |

|T ρ ρ ρ |Sonic | | |T ρ ρ ρ |seafood |

|U ρ ρ ρ |Subway | | |U ρ ρ ρ |breakfast/brunch place |

|V ρ ρ ρ |Taco Bell | | |V ρ ρ ρ |diner/neighborhood cafe |

|W ρ ρ ρ |Taco John | | |W ρ ρ ρ |all-you-can-eat buffet |

|X ρ ρ ρ |Wendy’s | | | | |

Food Exposures

Did your child have any of the following types of foods in the week prior to illness onset? Please provide as much detail as

possible, including size, type of package (plastic, paper box, etc.), organic, and other identifiers (e.g., flavors, fruits, nuts), etc.

For each item, give me a “yes” or “no” answer if you remember your child eating or even tasting it.

|[[v]] Y ? N |CEREAL |[[vi]] Y ? N |FRUIT / VEGGIE SNACKS |

|A ρ ρ ρ |Cereal |A ρ ρ ρ |Dried fruits |

|B ρ ρ ρ |Puffed cereal |B ρ ρ ρ |Fruit bars |

|C ρ ρ ρ |O-type cereal (e.g. Cheerios) |C ρ ρ ρ |Fruit puffs |

|D ρ ρ ρ |Infant cereal |D ρ ρ ρ |Frozen fruit |

|E ρ ρ ρ |Other cereal |E ρ ρ ρ |Jello |

|F ρ ρ ρ |Prepared with milk? |F ρ ρ ρ |If yes, was it homemade? |

|H ρ ρ ρ |Prepared with water? |G ρ ρ ρ |Vegetable puffs or crackers |

|I ρ ρ ρ |Prepared with yogurt? |H ρ ρ ρ |Dried vegetables |

|J ρ ρ ρ |Cereal bars |I ρ ρ ρ |Frozen vegetables |

|K ρ ρ ρ |Oatmeal | | |

|BRAND |TYPE |OTHER IDENTIFIERS |PACKAGING |ORGANIC (Y/N/DK) |PURCHASED |

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|[[vii]] Y ? N |FRESH FRUIT |[[viii]] Y ? N |FRESH VEGETABLES |

|A ρ ρ ρ |Apples |A ρ ρ ρ |Carrots |

|B ρ ρ ρ |Pears |B ρ ρ ρ |Celery |

|C ρ ρ ρ |Peaches |C ρ ρ ρ |Cucumbers |

|D ρ ρ ρ |Nectarines |D ρ ρ ρ |Broccoli |

|E ρ ρ ρ |Apricots |E ρ ρ ρ |Cauliflower |

|F ρ ρ ρ |Plums |F ρ ρ ρ |Bell peppers (green, yellow, orange, red) |

|G ρ ρ ρ |Oranges |G ρ ρ ρ |Other fresh peppers (chilies, jalapenos) |

|H ρ ρ ρ |Tangerines |H ρ ρ ρ |Asparagus |

|I ρ ρ ρ |Grapefruit |I ρ ρ ρ |Corn |

|J ρ ρ ρ |Lemon |J ρ ρ ρ |Peas |

|K ρ ρ ρ |Lime |K ρ ρ ρ |Beans |

|L ρ ρ ρ |Other citrus fruit |L ρ ρ ρ |Brussels sprouts |

|M ρ ρ ρ |Strawberries |M ρ ρ ρ |Zucchini or other soft squash |

|N ρ ρ ρ |Raspberries |N ρ ρ ρ |Hard squash |

|O ρ ρ ρ |Blueberries |O ρ ρ ρ |Potatoes |

|P ρ ρ ρ |Blackberries |P ρ ρ ρ |Yams or sweet potatoes |

|Q ρ ρ ρ |Cranberries |Q ρ ρ ρ |Tomatoes (if yes, please specify) |

|R ρ ρ ρ |Other fresh berries (specify) |R ρ ρ ρ |Cherry tomatoes |

|S ρ ρ ρ |Cherries |S ρ ρ ρ |Grape tomatoes V ρ cherry W ρ grape X ρ Roma Y ρ other |

|T ρ ρ ρ |Grapes |T ρ ρ ρ |(e.g., beefsteak) |

|U ρ ρ ρ |Bananas |U ρ ρ ρ |Roma tomatoes |

|V ρ ρ ρ |Plantains |V ρ ρ ρ |Other tomatoes (e.g. beefsteak) |

|W ρ ρ ρ |Cantaloupe |W ρ ρ ρ |White or yellow onions |

|X ρ ρ ρ |Honeydew |X ρ ρ ρ |Green onions |

|Y ρ ρ ρ |Watermelon |Y ρ ρ ρ |Eggplant |

|Z ρ ρ ρ |Other melon (specify) |Z ρ ρ ρ |Avocado |

| | | |Sprouts |

|[[ix]] Y ? N |FRESH FRUIT 2 |[[x]] Y ? N |FRESH VEGETABLES 2 |

|A ρ ρ ρ |Kiwi |A ρ ρ ρ |Cabbage |

|B ρ ρ ρ |Pineapple |B ρ ρ ρ |Lettuce (if yes, please specify) |

|C ρ ρ ρ |Mango |C ρ ρ ρ |Iceberg |

|D ρ ρ ρ |Papaya |D ρ ρ ρ |Romaine |

|E ρ ρ ρ |Pomegranate |E ρ ρ ρ |Other lettuce (specify) |

|F ρ ρ ρ |Other fruit (specify) |F ρ ρ ρ |Spinach |

|G ρ ρ ρ |Any fresh or unpasteurized fruit or vegetable juice? |G ρ ρ ρ |Greens (kale, collard, chard, etc.) |

|H ρ ρ ρ |Any packaged fruit or vegetable juice? |H ρ ρ ρ |Basil |

|I ρ ρ ρ |Apple juice? |I ρ ρ ρ |Parsley |

|J ρ ρ ρ |Orange juice? |J ρ ρ ρ |Cilantro |

|K ρ ρ ρ |Strawberry juice? |K ρ ρ ρ |Ginger |

|L ρ ρ ρ |Grape juice? |L ρ ρ ρ |Garlic |

|M ρ ρ ρ |Watermelon juice? |M ρ ρ ρ |Mushrooms |

|N ρ ρ ρ |Cranberry juice? |N ρ ρ ρ |Beets, turnips, or radishes |

|O ρ ρ ρ |Carrot juice? |O ρ ρ ρ |Okra |

|P ρ ρ ρ |Tomato juice? |P ρ ρ ρ |Rhubarb |

|Q ρ ρ ρ |Any blended juices? |Q ρ ρ ρ |Other vegetables (specify) |

| |If yes, specify blend __________________. | | |

|[[xi]] Y ? N |PRE PREPARED MAIN DISHES |[[xii]] Y ? N |SNACK FOODS |

|A ρ ρ ρ |Meat dishes, excluding poultry (specify) |A ρ ρ ρ |Biscuits (specify) |

|B ρ ρ ρ |Poultry dishes (specify) |B ρ ρ ρ |Chips (specify) |

|C ρ ρ ρ |Baby hot dogs |C ρ ρ ρ |Cookies (specify) |

|D ρ ρ ρ |Vegetable dishes (specify) |D ρ ρ ρ |Crackers (specify) |

|E ρ ρ ρ |Fish or seafood dishes (specify) |E ρ ρ ρ |Pretzels (specify) |

|F ρ ρ ρ |Pasta dishes (specify) |F ρ ρ ρ |Pirate’s booty |

|G ρ ρ ρ |Combination meal (specify) |G ρ ρ ρ |Rusks (specify) |

|H ρ ρ ρ |Other meal (specify) |H ρ ρ ρ |Other (specify) |

|BRAND |TYPE |OTHER IDENTIFIERS |PACKAGING |ORGANIC (Y/N/DK) |PURCHASED |

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|[[xiii]] Y ? N |DAIRY, EGGS, & CHEESE |[[xiv]] Y ? N |SOY PRODUCTS |

|A ρ ρ ρ |Milk: If yes, specify skim, 1%, 2%, or whole ________. |A ρ ρ ρ |Soy formula |

|B ρ ρ ρ |Milk-based infant formula |B ρ ρ ρ |Soy milk |

|C ρ ρ ρ |Milk-based desserts (e.g. pudding or shakes) |C ρ ρ ρ |Soy yogurt |

|D ρ ρ ρ |Any raw or unpasteurized milk? |D ρ ρ ρ |Soy butter |

|E ρ ρ ρ |Cheese |E ρ ρ ρ |Tofu |

|F ρ ρ ρ |Cheese products (mac & cheese, etc.) |F ρ ρ ρ |Egg substitutes |

|G ρ ρ ρ |Yogurt |G ρ ρ ρ |Quorn (frozen) |

|H ρ ρ ρ |Eggs, cooked (hard boiled, scrambled, etc.) |H ρ ρ ρ |Other (specify) |

|I ρ ρ ρ |Raw eggs or anything with raw eggs (cookie dough) | | |

|J ρ ρ ρ |Other eggs or dairy (specify) | | |

|BRAND |TYPE |OTHER IDENTIFIERS |PACKAGING |ORGANIC (Y/N/DK) |PURCHASED |

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|[[xv]] Y ? N |OTHER QUESTIONS |

|A ρ ρ ρ |Did your child use a NEW product designed to be put in the mouth (pacifier, sippy cup, etc.) within one week of illness onset? (specify). |

| |Do you clean your child’s teeth? |

|B ρ ρ ρ |If yes, brand of toothpaste _______________________? |

| |Do you have pets at home? |

|C ρ ρ ρ |Dogs or puppies? |

|D ρ ρ ρ |Cats or kittens? |

|E ρ ρ ρ |Reptiles? |

|F ρ ρ ρ |Birds? |

|G ρ ρ ρ |Other? (specify) |

|H ρ ρ ρ |If yes to any, please list all types of food or treats you fed the animals in the month prior to your child’s illness? |

|BRAND |TYPE |OTHER IDENTIFIERS |PACKAGING |ORGANIC (Y/N/DK) |PURCHASED |

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13. Where do you usually purchase food?

|STORE NAME |LOCATION |

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14. We may need to follow up for details, is it okay to contact you again?

15. Are there numbers, email addresses, or times at which it is best to contact you?

Thank you very much for answering these questions!

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[i]

[ii]

[iii]

[iv]

[v]

[vi]

[vii]

[viii]

[ix]

[x]

[xi]

[xii]

[xiii]

[xiv]

[xv]

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