Name |
Age |
Gender |
Phone Number/Email Address |
Date of Exposure |
Time |
Location |
Weather |
Surf Condition |
Activity/Time in Water |
Symptoms/Duration of Illness |
Anything unusual about the water (color, odor, foam, dead
organisms) |
Previous Exposure to Other Water Bodies |
Previous Exposure to Illness (family/friends) |
Did you seek medical attention? |
|