New York City Department of Health and Mental Hygiene Bathing Beaches Monitoring Program ILLNESS COMPLAINT FORM Name: First ___________________________ Last _____________________________ Telephone #: (______) ______________________ E-mail address: __________________________________ If you're filling this form out for a child please check here. Age of child: ______________________ If for an adult: Gender: Age: When did this illness occur? ____________________________________________________ Were there any of the following environmental factors present while you were swimming? Check all that apply: How would you describe the kind of contact you made with the water? How would you best describe your illness?If you have chronic infections year-round please don't check .) Check all that apply: What is the name of the beach where you were swimming? (Please include town or city) Approximately how many people were in the water? _______________________________________ Were there any other people at the beach with similar symptoms? Has this illness occurred more than once? If yes, did it occur at the same beach or a different beach? If it was a different beach, please give name and location ________________________________ Did you go to see a physician? If yes, did they relate your illness to swimming? Did you inform your doctor you were swimming? Was this before or after they diagnosed your illness? How did they diagnose your illness? Please explain: ____________________________________ What was the doctor's name and location? (optional, however this information may help us with our future studies) ____________________________________
