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Text File  |  1991-07-15  |  648 b   |  22 lines
  1.                  Questionnaire for Church Supper - Oswego
  2.  
  3.      Age:###                    Sex:<A>        Time of Supper(24 hour):####
  4.  
  5.      Ill? <Y>    {Onset Date} (MM/DD): <mm/dd>    {Onset Time} (24 hour):####
  6.  
  7.      Food History (Mark Y or N):
  8.              Baked Ham:<Y>
  9.              Spinach:<Y>
  10.              Mashed Potatoes:<Y>
  11.              Cabbage Salad:<Y>
  12.              Jello:<Y>
  13.              Rolls:<Y>
  14.              Brown Bread:<Y>
  15.              Milk:<Y>
  16.              Coffee:<Y>
  17.              Water:<Y>
  18.              Cakes:<Y>
  19.              Ice Cream:    {Vanilla}: <Y>        Chocolate:<Y>
  20.              Fruit Salad:  <Y>
  21.  
  22.