Food Consumption Report
DAILY HARVEST, INC.
QUESTIONS FOR PERSONS REPORTING ILLNESS OR ALLERGIC REACTION FROM CONSUMPTION OF FOOD
Information provided treated as CONFIDENTIAL
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Full Name *
Email *
Phone Number *
Address *
Food Name *
Product Code/Lot Number (The product code & lot number can be found on the bottom or side of the container, and will include the best by date, a 2 or 3 digit/letter code [examples: "L5-A", or "BB"]), and a time stamp.)
Best By Date
Purchase/Receipt Date
How was the food received? *
How was the food stored? *
Date(s) of use related to complaint *
Was the food consumed on a prior occasion? *
If so, when and how?
If so, any adverse reactions?
How was the food prepared? *
How long was it cooked (if applicable)? *
At what temperature?
Were other ingredients combined with the product? *
How was it served? *
What else was consumed at the same time (beverages, etc.)? *
How much was consumed? *
Did anyone else consume it? *
Did they have an adverse reaction?
If so, please complete a separate report for each other person with an adverse reaction.
After the incident, what did you do with the food? (please explain)
How soon after eating the food did you observe or experience an adverse reaction? (specify hours, minutes or days) *
Symptoms: Check all that apply
For each individual symptom mentioned above, please add how soon after eating they started, and how long they lasted?
Do you have a history of allergies?
Clear selection
OPTIONAL: Did you seek medical attention?
OPTIONAL: If desired, please provide any details including diagnosis and related information.
Why do you suspect this food was the cause of your illness? *
Other Information you wish to provide (if any).
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