{"id":2622,"date":"2017-03-07T14:48:06","date_gmt":"2017-03-07T18:48:06","guid":{"rendered":"http:\/\/phac.hyperinteractive.ca\/?page_id=2622"},"modified":"2025-04-11T13:10:17","modified_gmt":"2025-04-11T17:10:17","slug":"accessible-ecoli-hypothesis-generating-questionnaire","status":"publish","type":"page","link":"https:\/\/outbreaktools.ca\/fr\/tools\/toolkit-questionnaire-repository\/accessible-ecoli-hypothesis-generating-questionnaire\/","title":{"rendered":"Questionnaire g\u00e9n\u00e9rateur d’hypoth\u00e8ses visant l’E. coli"},"content":{"rendered":"

T\u00e9l\u00e9charger le format de rechange<\/a><\/p>\n

Contexte du questionnaire pour l’intervieweur<\/strong><\/p>\n

Ce questionnaire est con\u00e7u pour recueillir des renseignements complets sur les facteurs de risque possibles li\u00e9s \u00e0 l’E. coli<\/em>.\u00a0 Il est con\u00e7u pour des enqu\u00eates sur la grappe et l’\u00e9closion o\u00f9 la source d’infection est inconnue et o\u00f9 le questionnaire pourrait servir \u00e0 \u00e9tudier des cas sporadiques.<\/p>\n

Donn\u00e9es saisies\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 – Caract\u00e9ristiques d\u00e9mographiques des cas\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 – Expositions \u00e0 des aliments<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0– Donn\u00e9es cliniques\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0– Expositions aux animaux familiers<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0– Donn\u00e9es du laboratoire \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0– Autres facteurs de risque<\/p>\n

Puisque les \u00e9closions d’E. coli<\/em> sont souvent li\u00e9es \u00e0 des produits alimentaires contamin\u00e9s, il est essentiel de recueillir autant de d\u00e9tails que possible sur les expositions \u00e0 la nourriture.\u00a0 Par cons\u00e9quent, le pr\u00e9sent questionnaire pr\u00e9sente une historique alimentaire avec des questions \u00e0 r\u00e9ponses libres, suivis d’une liste d\u00e9taill\u00e9e d\u2019aliments; cela peut sembler r\u00e9p\u00e9titif, mais le but est de s’assurer que toutes les expositions possibles \u00e0 la nourriture sont saisies. Veuillez recueillir autant de d\u00e9tails que possible sur chaque aliment, y compris les expositions au restaurant.\u00a0 De plus, veuillez envisager la possibilit\u00e9 d’utiliser un calendrier pour examiner et recueillir les r\u00e9c\u00e9piss\u00e9s, les donn\u00e9es sur les achats ou les cartes de fid\u00e9lit\u00e9, le cas \u00e9ch\u00e9ant.<\/p>\n

Le questionnaire devrait prendre de 45 \u00e0 60\u00a0minutes \u00e0 remplir.<\/p>\n

R\u00e9serv\u00e9 \u00e0 l’usage local \u2013 veuillez supprimer cette page en cas d’envoi du formulaire \u00e0 l’aspc<\/h2>\n

No<\/sup> du dossier :\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 No d’identification national :<\/p>\n

I. Renseignements sur le cas<\/h3>\n\n\n\n\n\n\n\n
\n

Nom du cas :<\/p>\n<\/td>\n

\n

Nom du mandataire\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Num\u00e9ro de la carte de sant\u00e9 :<\/p>\n<\/td>\n

\u00a0<\/td>\n<\/tr>\n
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Adresse municipale :<\/p>\n

Ville\/Village :<\/p>\n

Code postal :<\/p>\n<\/td>\n

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T\u00e9l\u00e9phone \u00e0 domicile :<\/p>\n

T\u00e9l\u00e9phone au travail :<\/p>\n

T\u00e9l\u00e9phone cellulaire :<\/p>\n<\/td>\n<\/tr>\n

\n

M\u00e9decin :<\/p>\n<\/td>\n

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T\u00e9l\u00e9phone du m\u00e9decin :<\/p>\n<\/td>\n<\/tr>\n

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Profession :<\/p>\n<\/td>\n

\n

Lieu d’emploi :<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

II. Sympt\u00f4mes<\/h3>\n\n\n\n\n\n
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Date de d\u00e9but des symptoms (jj\/mm\/aa):\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Asymptomatique\u00a0:\u00a0 \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n<\/td>\n<\/tr>\n

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Sympt\u00f4mes\u00a0: \u00a0\u00a0\u00a0 Diarrh\u00e9e*\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u25a2 O \u25a2 N \u25a2 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Fi\u00e8vre\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u25a2 O \u25a2 N \u25a2 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Crampes abdominals \u00a0\u25a2 O \u25a2 N \u25a2 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Diarrh\u00e9e sanglante\u00a0\u00a0\u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0C\u00e9phal\u00e9e\u00a0 \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Naus\u00e9es \u00a0\u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0 Vomissements\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u25a2 O \u25a2 N \u25a2 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Autre\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u25a2 O \u25a2 N \u25a2 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0Si \u00ab\u00a0Autre\u00a0\u00bb, veuillez pr\u00e9ciser\u00a0:<\/p>\n

*3\u00a0selles aqueuses ou plus sur une p\u00e9riode de 24\u00a0heures<\/em><\/p>\n<\/td>\n<\/tr>\n

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Probl\u00e8mes m\u00e9dicaux sous-jacents ou m\u00e9dicaments qui inhibent le syst\u00e8me immunitaire<\/p>\n

(p. ex. grossesse, diab\u00e8te, cancer, st\u00e9ro\u00efdes)? \u25a2 O \u25a2 N \u25a2 NSP\u00a0Si oui, pr\u00e9cisez :<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

III. Contacts avec des personnes malades<\/h3>\n\n\n\n\n\n\n
\n

Avez-vous (ou le cas a-t-il) eu des contacts avec des personnes pr\u00e9sentant des sympt\u00f4mes similaires dans les dix\u00a0jours<\/strong> avant de devenir malade?\u00a0\u00a0\u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0 Si vous avez r\u00e9pondu \u00ab\u00a0Oui\u00a0\u00bb, pouvez-vous me dire qui?<\/p>\n

*Les contacts incluent les membres d’un m\u00e9nage, les partenaires sexuels, les personnes ayant pr\u00e9par\u00e9 la nourriture pour (vous ou le cas), les enfants ou les adultes que vous ou le cas avez aid\u00e9s \u00e0 utiliser les toilettes ou \u00e0 changer les couches, ou toute autre personne avec qui vous ou le cas \u00eates entr\u00e9 en contact par le vomi ou les selles.<\/em><\/p>\n<\/td>\n<\/tr>\n

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Nom :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Genre:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Num\u00e9ro de t\u00e9l\u00e9phone :<\/p>\n

Lien avec le cas :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00c2ge:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Date de l’apparition de la diarrh\u00e9e (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n

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Nom :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Genre:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Num\u00e9ro de t\u00e9l\u00e9phone :<\/p>\n

Lien avec le cas :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00c2ge:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Date de l’apparition de la diarrh\u00e9e (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n

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Nom :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Genre:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Num\u00e9ro de t\u00e9l\u00e9phone :<\/p>\n

Lien avec le cas :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00c2ge:\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Date de l’apparition de la diarrh\u00e9e (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Questionnaire g\u00e9n\u00e9rateur d’hypoth\u00e8ses visant l’E. coli<\/h2>\n

No d’identification national :<\/p>\n

Section 1 : Renseignements sur le cas<\/h3>\n\n\n\n\n\n\n\n
\n

Cas interrog\u00e9 par :<\/p>\n<\/td>\n

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Date de l’entrevue (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n

Bureau ou autorit\u00e9 de sant\u00e9 :<\/td>\n\n

Date de d\u00e9claration au bureau ou \u00e0 l’autorit\u00e9 de sant\u00e9 (jj\/mm\/aa):<\/p>\n<\/td>\n<\/tr>\n

Province ou territoire :<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

R\u00e9pondant : \u25a2 Cas \u25a2 Parent \u25a2 Conjoint \u2610 Soignant \u2610 Autre (pr\u00e9ciser)\u00a0: ______________________________<\/p>\n<\/td>\n<\/tr>\n

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\u00c2ge :<\/p>\n<\/td>\n

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Genre\u00a0:\u00a0\u00a0 \u2610\u00a0 M\u00a0\u00a0\u00a0 \u2610\u00a0 F\u00a0\u00a0\u00a0 \u2610\u00a0 Autre\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 Pas demand\u00e9\/Inconnu\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 2 : Donn\u00e9es cliniques<\/h3>\n\n\n\n\n\n\n\n\n
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 <\/p>\n

 <\/p>\n

\u00c0 remplir par l\u2019intervieweur<\/strong><\/p>\n<\/td>\n

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S\u00e9rotype :<\/p>\n<\/td>\n

\n

Code d\u2019agr\u00e9gat par s\u00e9quen\u00e7age du g\u00e9nome entier\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Type d’\u00e9chantillon positif :<\/p>\n

\u25a2 Selles \u25a2 Sang \u25a2 Urine \u25a2 Autre (pr\u00e9ciser) :<\/p>\n<\/td>\n

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Date du premier pr\u00e9l\u00e8vement des \u00e9chantillons positifs (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n

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Date d\u2019 apparition des premiers sympt\u00f4mes (jj\/mm\/aa):<\/p>\n

Asymptomatique? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n<\/td>\n

\n

Date d’apparition de la diarrh\u00e9e (jj\/mm\/aa) :<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

Admission* \u00e0 l’h\u00f4pital en raison de la maladie? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

*Ne comprend pas les personnes qui se rendent \u00e0 une salle d’urgence ou \u00e0 une clinique externe<\/p>\n<\/td>\n

\n

Date de l’admission (jj\/mm\/aa):<\/p>\n

Date du cong\u00e9 (jj\/mm\/aa):\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u25a2 Toujours hospitalise<\/p>\n<\/td>\n<\/tr>\n

\u00c0 remplir par l\u2019intervieweur<\/strong><\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Syndrome h\u00e9molytique et ur\u00e9mique? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n<\/td>\n

\n

Autres complications? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

Si oui, pr\u00e9cisez\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Cas d\u00e9c\u00e9d\u00e9? \u25a2 O \u25a2 N Date de d\u00e9c\u00e8s (jj\/mm\/aa) :<\/p>\n

Si oui, l’infection \u00e0 l’E. coli<\/em> est-elle la cause sous-jacente du d\u00e9c\u00e8s ou ayant contribu\u00e9 au d\u00e9c\u00e8s? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

Si oui, la d\u00e9termination est-elle fond\u00e9e sur le certificat de d\u00e9c\u00e8s? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 3 : Renseignements relatifs aux voyages<\/h3>\n\n\n\n\n
\n

Dans les dix jours<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, c\u2019est-\u00e0-dire du j____ \/ m_____ \/ a_____ au j____ \/ m____ \/ a____, avez-vous (ou le cas a-t-il) voyag\u00e9 au Canada ou \u00e0 l\u2019ext\u00e9rieur du Canada?\u00a0 \u00a0\u25a2 O \u25a2 N \u25a2 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

Si la r\u00e9ponse est oui : \u25a2 \u00c0 l’int\u00e9rieur de la province ou duterritoire \u25a2 Dans d’autres provinces ou territoires \u25a2 \u00c0 l’ext\u00e9rieur du Canada<\/p>\n

Pr\u00e9cisez la ou les destinations (pays\/ville\/vill\u00e9giature) :<\/p>\n

D\u00e9part (jj\/mm\/aa):\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Retour (jj\/mm\/aa):<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 4 : R\u00e9gimes sp\u00e9ciaux ou pr\u00e9f\u00e9rences alimentaires<\/h3>\n\n\n\n\n\n\n
\n

Tout d\u2019abord, je tiens \u00e0 vous poser quelques questions g\u00e9n\u00e9rales sur le r\u00e9gime alimentaire et les pr\u00e9f\u00e9rences alimentaires (les v\u00f4tres ou ceux du cas).<\/p>\n

\u00cates-vous (ou le cas est-il) v\u00e9g\u00e9tarien? \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

Si oui, mangez-vous (ou le cas mange-t-il) :<\/p>\n

\u0152ufs \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Produits laitiers \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Poisson \u25a2 O \u25a2 N \u25a2 NSP<\/p>\n

Volaille \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Viandes rouges \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Autres viandes \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0 Si oui, pr\u00e9cisez\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u00cates-vous (ou le cas est-il) allergique \u00e0 des aliments? \u25a2 O \u25a2 N \u25a2 NSP Si oui, pr\u00e9cisez les aliments :<\/p>\n<\/td>\n<\/tr>\n

\n

Y a-t-il des aliments ou des groupes alimentaires que vous (ou le cas) ne mangez jamais? \u25a2 O \u25a2 N \u25a2 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, pr\u00e9cisez :<\/p>\n<\/td>\n<\/tr>\n

\n

Dans les\u00a0dix jours<\/strong> avant l’apparition de la maladie, suiviez-vous (ou le cas suivait-il) :<\/p>\n

Un r\u00e9gime sp\u00e9cial ou restreint? (p. ex. un r\u00e9gime d’aliments crus, v\u00e9g\u00e9talien, pour diab\u00e9tiques, casher, halal)<\/p>\n

\u25a2 O \u25a2 N \u25a2 NSP Si oui, d\u00e9crivez :<\/p>\n

Est-ce que vous-m\u00eame ou le cas avez consomm\u00e9 un compl\u00e9ment alimentaire ou un suppl\u00e9ment nutritif (p. ex., substituts de repas, poudre de prot\u00e9ines, vitamines, herbes, kratom)?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u25a2 O \u25a2 N \u25a2 NSP Si oui, d\u00e9crivez :<\/p>\n

Avez-vous consomm\u00e9 des boissons sant\u00e9 pr\u00e9par\u00e9es et embouteill\u00e9es? (p.\u00a0ex.\u00a0Kombucha, eau de noix de coco)\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u25a2 O \u25a2 N \u25a2 NSP Si oui, d\u00e9crivez :<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 5 : Consommation d\u2019aliments \u00e0 l\u2019ext\u00e9rieur du domicile<\/strong><\/h3>\n

Dans les dix jours<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, avez-vous (ou le cas a-t-il) consomm\u00e9 des aliments \u00e0 l\u2019ext\u00e9rieur du domicile, soit dans un rassemblement social ou \u00e0 l\u2019un des \u00e9tablissements alimentaires suivants? (y compris les aliments achet\u00e9s\/command\u00e9s dans un restaurant et consomm\u00e9s \u00e0 la maison et des \u00e9chantillons consomm\u00e9s \u00e0 des \u00e9tablissements comme des supermarch\u00e9s).<\/p>\n\n\n\n\n\n
\n

Types de rassemblement social\/ \u00c9tablissement alimentaire<\/strong><\/p>\n<\/th>\n

\n

Details des aliments consomm\u00e9s\u00a0<\/strong><\/p>\n<\/th>\n<\/tr>\n<\/thead>\n

\n

Rassemblement ou \u00e9v\u00e9nement social (p.\u00a0ex. au domicile d\u2019un ami ou d\u2019un membre de la famille, collations au travail, congr\u00e8s, mariage ou soir\u00e9e)<\/p>\n

\u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Si oui, connaissez-vous d\u2019autres personnes qui ont pr\u00e9sent\u00e9 des diarrh\u00e9es apr\u00e8s<\/u> ce rassemblement?<\/em><\/p>\n

\u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0 \u00a0\u00a0<\/p>\n

Si oui, combien? ______<\/p>\n<\/td>\n

\n

Nom de l\u2019\u00e9v\u00e9nement\/description\u00a0:<\/p>\n

 <\/p>\n

Lieu\u00a0:<\/p>\n

 <\/p>\n

Date du rassemblement\u00a0: j_____ \/ m______ \/a_____<\/p>\n

 <\/p>\n

Nombre de personnes pr\u00e9sentes\u00a0:<\/p>\n<\/td>\n

\n

\u00a0<\/em><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n\n\n\n\n\n\n
Avez-vous mang\u00e9 du pr\u00eat-\u00e0-manger ou dans un autre restaurant? Il pourrait s\u2019agir de nourriture ou de boissons provenant d\u2019un caf\u00e9, d\u2019une caf\u00e9t\u00e9ria, d\u2019un marchand ambulant, d\u2019un kiosque ou d\u2019un d\u00e9panneur. \u00c9num\u00e9rez \u00e9galement tout \u00e9chantillon d\u2019un supermarch\u00e9.<\/td>\n<\/tr>\n
Nom de l\u2019\u00e9tablissement alimentaire<\/strong><\/td>\nAdresse\/emplacement<\/strong><\/td>\nDates(s)<\/strong><\/td>\nAliments command\u00e9s\/ consomm\u00e9s<\/strong><\/td>\n<\/tr>\n
\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

D\u00e9tails suppl\u00e9mentaires sur les \u00e9tablissements alimentaires mentionn\u00e9s ci-dessus\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\u00a0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 6 : Achat d\u2019aliments pour consommation \u00e0 domicile<\/strong><\/h3>\n

O\u00f9 est-ce que vous-m\u00eame ou le cas achetez habituellement les aliments pour la consommation \u00e0 domicile? Il peut s\u2019agir d\u2019\u00e9piceries, de march\u00e9s fermiers, d\u2019\u00e9piceries sp\u00e9cialis\u00e9es, de banques alimentaires ou d\u2019achats en ligne comme Amazon, Well.ca ou d\u2019autres commerces en ligne.<\/p>\n

*Le formulaire de consentement pour la collecte de renseignements sur la carte de fid\u00e9lit\u00e9 est disponible aupr\u00e8s de l\u2019autorit\u00e9 de sant\u00e9 de votre province ou territoire, ou de l\u2019ASPC.<\/p>\n\n\n\n\n\n\n\n\n\n
\u00a0<\/th>\nNom du magasin<\/th>\nEndroit\/Adresse<\/th>\n<\/tr>\n
\n

A<\/p>\n<\/td>\n

\n

Nom du commerce ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0 \u2610 N\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

B<\/p>\n<\/td>\n

\n

Nom du commerce ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0 \u2610 N\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

C<\/p>\n<\/td>\n

\n

Nom du commerce ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0 \u2610 N\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

D<\/p>\n<\/td>\n

\n

Nom du commerce ou du site Web\u00a0:<\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0 \u2610 N\u00a0<\/p>\n<\/td>\n<\/tr>\n

Renseignements suppl\u00e9mentaires sur les commerces mentionn\u00e9s ci-dessus. Le cas \u00e9ch\u00e9ant, veuillez fournir des renseignements sur les achats types effectu\u00e9s dans les magasins sp\u00e9cialis\u00e9s ou en ligne ainsi que des d\u00e9tails sur la m\u00e9thode d\u2019achat et indiquer si le cas est dispos\u00e9 \u00e0 pr\u00e9senter les re\u00e7us, les factures, etc.<\/td>\n<\/tr>\n
\u00a0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 7 : Achat de repas pr\u00eat-\u00e0-cuisiner<\/strong><\/h3>\n

Au cours des dix jours<\/strong> pr\u00e9c\u00e9dant l\u2019apparition de la maladie, est-ce que vous-m\u00eame ou le cas avez consomm\u00e9 des aliments pr\u00e9par\u00e9s \u00e0 partir de repas pr\u00eat-\u00e0-cuisiner (Goodfood, Hello Fresh, Chef\u2019s Plate, Red Apron, etc.)?<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0\u00a0\u00a0\u00a0Si oui, veuillez fournir les renseignements demand\u00e9s ci-dessous.<\/strong><\/p>\n\n\n\n\n
\n

Renseignements sur l\u2019achat <\/strong><\/p>\n<\/td>\n

\n

Noms des repas, dates de consommation, ingr\u00e9dients et substitutions<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Nom de l\u2019entreprise\u00a0:<\/strong><\/p>\n

Date de livraison\u00a0:<\/strong><\/p>\n

Des re\u00e7us, des factures, des avis par courriel ou des fiches de recette sont-ils disponibles?<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0\u00a0\u00a0\u00a0<\/strong><\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Section 8 : Aliments consomm\u00e9s dans les dix\u00a0jours pr\u00e9c\u00e9dant le d\u00e9but de la maladie <\/strong><\/h3>\n

J\u2019aimerais vous parler des aliments ou des boissons que vous avez (ou que le cas a) consomm\u00e9s avant de devenir malade. En commen\u00e7ant par la journ\u00e9e o\u00f9 vous avez ou le cas a connu les premiers sympt\u00f4mes\u00a0:<\/p>\n

(Note \u00e0 l\u2019intention de l\u2019intervieweur\u00a0: Veuillez demander o\u00f9 les aliments ont \u00e9t\u00e9 consomm\u00e9s ou comment ils ont \u00e9t\u00e9 pr\u00e9par\u00e9s, p. ex. pr\u00e9par\u00e9s et consomm\u00e9s \u00e0 la maison, consomm\u00e9s dans un restaurant, comptoir de commandes \u00e0 emporter, repas pr\u00eats-\u00e0-manger, repas surgel\u00e9s, etc.)<\/em><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Journ\u00e9e de la maladie\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener<\/p>\n<\/td>\n

\n

Souper\u00a0\u00a0<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Une journ\u00e9e avant le d\u00e9but de la maladie\u00a0\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Deux jours avant le d\u00e9but de la maladie \u00a0(jj\/mm\/aa)<\/strong>\u00a0\u00a0 \u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Trois jours avant le d\u00e9but de la maladie\u00a0\u00a0 \u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Quatre jours avant le d\u00e9but de la maladie\u00a0\u00a0 \u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Cinq jours avant le d\u00e9but de la maladie:<\/em>\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Six jours avant le d\u00e9but de la maladie\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Sept jours avant le d\u00e9but de la maladie\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Huit jours avant le d\u00e9but de la maladie\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Neuf jours avant le d\u00e9but de la maladie\u00a0\u00a0\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n
\n

Dix jours avant le d\u00e9but de la maladie\u00a0\u00a0 (jj\/mm\/aa)<\/strong>\u00a0\u00a0\u25a2\u00a0Lun \u25a2\u00a0Mar \u25a2\u00a0Mer \u25a2\u00a0Jeu \u25a2 Ven \u25a2 Sam \u25a2 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

D\u00eener<\/td>\nSouper<\/td>\nCollations<\/td>\n<\/tr>\n
\n

 <\/p>\n

 <\/p>\n<\/td>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h2>\n

\u00a0<\/h3>\n

\u00a0<\/h3>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

Section 9 : Expositions \u00e0 des aliments<\/strong><\/h3>\n

DIRECTIVES \u00c0 LIRE AU CAS<\/p>\n

J\u2019aimerais conna\u00eetre les aliments que vous avez (ou que le cas a) consomm\u00e9s au cours des dix\u00a0journ\u00e9es<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, c\u2019est-\u00e0-dire du j____\/m_____\/a_____ au j____\/m____\/a____.\u00a0 Pour chaque aliment, veuillez me donner votre meilleure estimation \u00e0 savoir si l\u2019aliment a \u00e9t\u00e9 consomm\u00e9, si vous n\u2019\u00eates pas s\u00fbr de l\u2019avoir consomm\u00e9, mais que vous l\u2019avez probablement fait ou si vous ne l\u2019avez pas consomm\u00e9. Veuillez inclure les aliments mang\u00e9s seuls ou dans une salade, un sandwich ou un mets.<\/p>\n

DIRECTIVES \u00c0 L\u2019INTENTION DE L\u2019INTERVIEWEUR<\/p>\n

Pour chaque aliment consomm\u00e9 par le cas, demandez la marque et le lieu d\u2019achat du produit. Veuillez s\u00e9lectionner une r\u00e9ponse pour chaque question ou indiquer si la question n\u2019a pas \u00e9t\u00e9 pos\u00e9e.\u00a0 Il y a quatre options possibles pour chaque exposition \u00e0 des aliments.<\/p>\n

Oui \u2013 Le cas a consomm\u00e9<\/strong> l\u2019aliment\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 NSP \u2013 Le cas ne sait pas<\/strong> s\u2019il a consomm\u00e9 l\u2019aliment<\/p>\n

Prob. \u2013 Le cas a probablement<\/strong> consomm\u00e9 l\u2019aliment\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Non \u2013 Le cas n\u2019a pas consomm\u00e9<\/strong> l\u2019aliment<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

Oui<\/strong><\/p>\n<\/td>\n

\n

Prob.<\/strong><\/p>\n<\/td>\n

\n

Non<\/strong><\/p>\n<\/td>\n

\n

NSP<\/strong><\/p>\n<\/td>\n

\n

IMPORTANT. Veuillez inclure autant de pr\u00e9cisions que possible<\/em><\/strong><\/p>\n

Type\/Vari\u00e9t\u00e9\/Marque<\/strong><\/p>\n<\/td>\n

\n

Lieu d\u2019achat ou de consommation de l\u2019aliment\u00a0:<\/strong><\/p>\n

Pr\u00e9cisez le nom de l\u2019\u00e9picerie ou du restaurant<\/em><\/p>\n<\/td>\n<\/tr>\n<\/thead>\n

\n

B\u0152UF<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de b\u0153uf (excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de b\u0153uf hach\u00e9 (p.\u00a0ex.\u00a0hamburger, lasagne, chili)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hamburger (p.\u00a0ex. galettes \u00e0 hamburger)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hamburger fait maison avec du b\u0153uf hach\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Galettes de b\u0153uf congel\u00e9es du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Galettes de b\u0153uf fra\u00eeches du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hamburger provenant d\u2019un restaurant<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout autre type de b\u0153uf hach\u00e9 (p.\u00a0ex. boulettes de viande, chili, spaghetti)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

B\u0153uf hach\u00e9 consomm\u00e9 cru ou peu cuit (p. ex. hamburgers pas assez cuits ou kebb\u00e9s)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

B\u0153uf cru (e.g. carpaccio, tartare)<\/p>\n

achet\u00e9 \u2610 frais \u2610 congel\u00e9 \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Steak<\/p>\n

achet\u00e9 \u2610 frais \u2610 congel\u00e9 \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

B\u0153uf \u00e0 rago\u00fbt<\/p>\n

achet\u00e9 \u2610 frais \u2610 congel\u00e9 \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre pi\u00e8ce de b\u0153uf (p.\u00a0ex. r\u00f4ti, c\u00f4tes)<\/p>\n

achet\u00e9 \u2610 frais \u2610 congel\u00e9 \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Veau<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de b\u0153uf (en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

PORC<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de porc (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Jambon (en excluant la charcuterie)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Bacon<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Porc hach\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Morceaux de porc (p.\u00a0ex. r\u00f4tis de porc, c\u00f4tes lev\u00e9es, c\u00f4telettes, dans une soupe ou un mets, en excluant la charcuterie ou le jambon)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de porc (en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

VOLAILLE<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de poulet (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poulet pan\u00e9 achet\u00e9 en magasin (p.\u00a0ex. croquettes, lani\u00e8res ou burgers de poulet)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Produit de poulet farci achet\u00e9 en magasin (p. ex. poulet \u00e0 la Kiev, poulet cordon bleu)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poulet hach\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Morceaux de poulet (p.\u00a0ex. poulet entier r\u00f4ti, poitrines, ailes, cuisses, dans une soupe ou un mets, en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de poulet (en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de dinde (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Dinde hach\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Morceaux de dinde (p.\u00a0ex. dinde enti\u00e8re r\u00f4tie, poitrines, ailes, cuisses, dans une soupe ou un mets, en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de dinde (en excluant la charcuterie) (p.\u00a0ex. bacon de dinde)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de volaille (p.\u00a0ex. poulet de Cornouailles, canard, en excluant la charcuterie)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

\u0152UFS ET PLATS CONTENANT DES \u0152UFS<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

\u0152ufs (p.\u00a0ex. \u0153ufs brouill\u00e9s, omelettes)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ____________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u0152ufs consomm\u00e9s crus ou peu cuits (p.\u00a0ex. \u00ab\u00a0dont le jaune est coulant\u00a0\u00bb ou \u00ab\u00a0\u0153ufs tourn\u00e9s\u00a0\u00bb), tout produit fait avec des \u0153ufs crus (p.\u00a0ex. p\u00e2te \u00e0 biscuits crue, pr\u00e9paration pour g\u00e2teau, sauces, cr\u00e8me glac\u00e9e fait maison, mayonnaise, vinaigrette, ou dans une boisson)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

AUTRES VIANDES OU PRODUITS ANIMAUX <\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Charcuterie\/viande froide (p.\u00a0ex. saucisson de Bologne, salami, pepperoni, dinde, jambon)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Charcuteries pr\u00e9emball\u00e9es<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Charcuterie tranch\u00e9e au comptoir de charcuterie<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hot-dogs ou saucisses sur b\u00e2tonnet<\/p>\n

Si oui, chauff\u00e9 avant d\u2019\u00eatre consomm\u00e9 <\/em><\/p>\n

\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Saucisse<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Saucisse de b\u0153uf<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Saucisse de porc<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Saucisse de poulet<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Saucisse de dinde<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Produits de viande s\u00e9ch\u00e9e\/fum\u00e9e (p.\u00a0ex. pepperettes, saucisse s\u00e9ch\u00e9e, saucisson)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00e2t\u00e9\/viande \u00e0 tartiner<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Agneau<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Ch\u00e8vre<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de gibier ou de nourriture traditionnelle (p. ex. venaison, faisan, li\u00e8vre, caribou, phoque, cailles, orignal, bison)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Abats (p. ex. foie, rein, c\u0153ur)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Shawarma\/donair\/gyro<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande, excluant le poisson et les fruits de mer<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

POISSONS ET FRUITS DE MER<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout poisson (y compris poisson frais, en conserve, en pot, surgel\u00e9)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poisson fum\u00e9 (p.\u00a0ex. saumon fum\u00e9)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poisson consomm\u00e9 cru (p.\u00a0ex. sushi, tartare, sashimi, ceviche)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre type de poisson (p.\u00a0ex. frais, congel\u00e9, cuit, s\u00e9ch\u00e9)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mollusques et crustac\u00e9s<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Moules<\/p>\n

Si oui, mang\u00e9es crues <\/em>\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Palourdes<\/p>\n

Si oui, mang\u00e9es crues <\/em>\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Crevettes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n

Si oui, mang\u00e9es crues <\/em>\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hu\u00eetres<\/p>\n

\u00a0Si oui, mang\u00e9es crues <\/em>\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout autre mollusque ou crustac\u00e9 (p.\u00a0ex.\u00a0p\u00e9toncle, coque, crabe, \u00e9crevisse, homard)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n

Si oui, mang\u00e9 cru <\/em>\u2610 O \u2610 N \u2610 NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres fruits de mer ou produits d\u2019algues<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

PRODUITS LAITIERS ET SUBSTITUTS LAITIERS<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Lait pasteuris\u00e9<\/p>\n

Si oui, pr\u00e9cisez\u00a0: _____________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Lait non pasteuris\u00e9 (cru)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Boisson v\u00e9g\u00e9tale (p.\u00a0ex. soja, amande, noix de coco, riz, noix de cajou, avoine)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres produits non laitiers\/substituts de produits laitiers (p.\u00a0ex.\u00a0yogourt, cr\u00e8me sure, cr\u00e8me glac\u00e9e sans produits laitiers)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Produits laitiers en poudre (p. ex. lait en poudre, \u00e9vapor\u00e9 Carnation, de marque Ovaltine)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cr\u00e8me fouett\u00e9e ou \u00e0 fouetter<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cr\u00e8me sure<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cr\u00e8me glac\u00e9e\/gelato<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Desserts contenant du lait ou de la cr\u00e8me (p.\u00a0ex.\u00a0tartes\/p\u00e2tisseries fourr\u00e9es \u00e0 la cr\u00e8me, pouding)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Yogourt<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres produits laitiers<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

FROMAGE<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de fromage<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage cheddar<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage mozzarella<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage parmesan<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Gouda<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage feta<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromages \u00e0 p\u00e2te molle comme le brie, le camembert<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromages persill\u00e9s comme le fromage bleu ou le gorgonzola<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage cottage, ricotta ou autre fromage frais<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage \u00e0 base de lait de ch\u00e8vre ou de brebis<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout autre fromage g\u00e9n\u00e9ralement vendu en bloc ou tranch\u00e9 \u00e0 partir d\u2019une meule (p.\u00a0ex. emmental, jarlsberg, monterey jack, havarti, colby ou oka)<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage fondu (p. ex. fromage en tranches, fromage en lani\u00e8res ou en b\u00e2tonnets, en pot)<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout fromage \u00e0 base de lait non pasteuris\u00e9 (cru)<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Substituts de fromage non laitiers<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: __________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

L\u00c9GUMES<\/strong>\u00a0: Inclure les l\u00e9gumes crus ou cuits (exclure les l\u00e9gumes en conserve)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de tomate, y compris dans un plat ou un repas comme une salade, un sandwich, un burger ou un taco<\/p>\n

Si oui, veuillez pr\u00e9ciser\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tomates cerises ou raisins<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Laitue ou l\u00e9gume-feuille, y compris dans un plat ou un repas comme une salade, un sandwich, un burger ou un taco<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Iceberg<\/p>\n

\u2610 pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e\/t\u00eate<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Romaine<\/p>\n

\u2610 pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e\/t\u00eate<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9pinards<\/p>\n

\u2610 pr\u00e9emball\u00e9s \u2610 non pr\u00e9emball\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Laitue mesclun\/m\u00e9lange printanier<\/p>\n

\u2610 pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Kale<\/p>\n

\u2610 Pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Roquette<\/p>\n

\u2610 Pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres laitues ou l\u00e9gumes-feuilles<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n

\u2610 pr\u00e9emball\u00e9s \u2610 non pr\u00e9emball\u00e9s\/t\u00eate<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salades pr\u00e9emball\u00e9es du commerce (p.\u00a0ex. dans un sac ou un contenant, peut comprendre la vinaigrette et la garniture), excluant les salades pr\u00e9par\u00e9es pr\u00eates \u00e0 manger<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade verte pr\u00e9par\u00e9e ou pr\u00eate \u00e0 manger du commerce (p.\u00a0ex. salade C\u00e9sar pr\u00e9par\u00e9e, salade de kale, salade du jardin, salade d\u2019\u00e9pinards)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de pommes de terre du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de p\u00e2tes du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre salade du commerce (p.\u00a0ex. grecque, quinoa, haricots)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Chou (p.\u00a0ex.\u00a0entier, hach\u00e9, salade de chou)<\/p>\n

\u2610 pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9\/t\u00eate<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de chou<\/p>\n

\u2610 pr\u00e9emball\u00e9e \u2610 fait maison<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Micropousses ou germes, y compris dans un plat ou un repas comme dans un sandwich ou une salade (p.\u00a0ex.\u00a0germes de haricot ou de luzerne, micropousses de brocoli)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Micropousses<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Luzerne<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Germes de haricot<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres germes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Concombres<\/p>\n

\u2610 anglais\u00a0\u00a0\u00a0\u00a0 \u2610 de champ\u00a0\u00a0\u00a0\u00a0 \u2610 Mini<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poivrons (p. ex. rouges, verts, jaunes)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Piments forts (p.\u00a0ex. jalape\u00f1o, serrano, habanero)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

C\u00e9leri<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Carottes (non mini)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mini-carottes (ou miniatures)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Pois (frais, cosses de pois crues, pois mange-tout)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Haricots verts ou jaunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Brocoli<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Chou-fleur<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Radis<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons\u00a0<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons blancs ou jaunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons verts<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons rouges<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres oignons<\/p>\n

Si oui, pr\u00e9cisez\u00a0: __________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poireaux<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Ail frais (pas en poudre)\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Gingembre frais (non moulu)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Champignons<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Courgettes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres l\u00e9gumes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: _____________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

L\u00e9gumes congel\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

L\u00e9gumes ferment\u00e9s (p.\u00a0ex.\u00a0kimchi, choucroute)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Jus de l\u00e9gumes (p.\u00a0ex.\u00a0jus de tomate, jus de carotte)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

FRUITS\u00a0:<\/strong> Inclure les fruits crus ou cuits (exclure les fruits en conserve)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Salade de fruits\/fruits pr\u00e9coup\u00e9s ou plateau de fruits<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melons<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cantaloup<\/p>\n

\u2610 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melon miel<\/p>\n

\u2610 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melon d\u2019eau<\/p>\n

\u2610 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres melons<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Pommes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poires<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00eaches<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Nectarines<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Abricots<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Prunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Agrumes (p.\u00a0ex.\u00a0oranges, pamplemousses, citrons, limes)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Petits fruits (baies)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fraises<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Framboises<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Bleuets<\/p>\n

\u2610 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9s\u00a0 \u2610 S\u00e9ch\u00e9s\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

M\u00fbres<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres baies (p.\u00a0ex.\u00a0canneberges, groseilles \u00e0 maquereau, framboises-m\u00fbres de Tay)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Sac de baies ou fruits m\u00e9lang\u00e9s congel\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cerises<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Raisins<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Bananes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mangues<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Papayes<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Kiwis<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Grenades<\/p>\n

\u2610 Fra\u00eeche (y compris les p\u00e9pins pr\u00eats \u00e0 manger)\u00a0<\/p>\n

\u2610 Congel\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Ananas<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Noix de coco<\/p>\n

\u2610 Fra\u00eeche\u00a0\u00a0\u00a0 \u2610 Congel\u00e9e\u00a0 \u2610 S\u00e9ch\u00e9e\/r\u00e2p\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Avocat (y compris le guacamole)<\/p>\n

\u2610 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Olives<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres fruits<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cidre de pommes ou jus de fruits non pasteuris\u00e9<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: ___________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

Boisson fouett\u00e9e aux fruits contenant des fruits ou l\u00e9gumes frais ou congel\u00e9s, pr\u00e9par\u00e9e \u00e0 la maison ou achet\u00e9e fra\u00eeche dans un commerce, un restaurant ou un caf\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Boisson fouett\u00e9e pr\u00e9par\u00e9e, en bouteille<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

HERBES ET \u00c9PICES\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Basilic frais<\/p>\n

\u2610 Tha\u00ef\u00a0\u00a0\u00a0\u00a0 \u2610 Traditionnel<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Coriandre fra\u00eeche<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Persil frais<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres herbes fra\u00eeches (p.\u00a0ex. origan, aneth, menthe, romarin, ciboulette, thym)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: __________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Herbes ou \u00e9pices s\u00e9ch\u00e9es<\/p>\n

Si oui, pr\u00e9cisez\u00a0: _____________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

TARTINADES ET TREMPETTES PR\u00c9PAR\u00c9ES DU COMMERCE<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Salsa<\/p>\n

\u2610 Fra\u00eeche (p. ex., pico de gallo)\u00a0\u00a0\u00a0<\/p>\n

\u2610 Dans un pot en verre ou une bo\u00eete de conserve<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Houmous achet\u00e9 dans un commerce ou un restaurant (excluant le houmous fait maison)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Toute autre trempette<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

ALIMENTS CONGEL\u00c9S\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Pizzas congel\u00e9es<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00e2t\u00e9s congel\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Repas congel\u00e9s dans un sac ou une bo\u00eete (p.\u00a0ex.\u00a0saut\u00e9s, plats cuisin\u00e9s congel\u00e9s)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Collations ou entr\u00e9es congel\u00e9es (p.\u00a0ex. b\u00e2tonnets de fromage mozzarella, piments jalape\u00f1o farcis, frites)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres aliments congel\u00e9s (p.\u00a0ex.\u00a0g\u00e2teaux surgel\u00e9s, p\u00e2te \u00e0 biscuits surgel\u00e9e, tartes, tourtes, choux \u00e0 la cr\u00e8me, gaufres)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

NOIX ET GRAINES\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Noix consomm\u00e9es seules, en m\u00e9lange, en beurre\/tartinade ou dans un lait de noix fait maison, dans une barre granola, en garniture ou dans un plat<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Arachides (excluant le beurre\/tartinade d\u2019arachides)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Beurre\/tartinade d\u2019arachides<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Amandes (excluant le beurre\/tartinade d\u2019amandes)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Beurre\/tartinade d\u2019amandes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Noix de Grenoble<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Noisettes\/avelines (excluant le beurre\/tartinade de noisettes)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Beurre\/tartinade contenant des noisettes (p.\u00a0ex.\u00a0Nutella)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Noix de cajou (excluant le beurre\/tartinade de noix de cajou)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Pacanes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres noix (p.\u00a0ex.\u00a0noix macadamia, noix du Br\u00e9sil, pistaches, noix de pin)<\/p>\n

Si oui, pr\u00e9cisez<\/em>\u00a0: ___________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00e2te, beurre ou tartinade de noix (p.\u00a0ex.\u00a0beurre de noix du Br\u00e9sil, beurre de pistaches)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Graines de tournesol\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Beurre ou p\u00e2te contenant des graines de tournesol<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Graines de s\u00e9same<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tahini (beurre de s\u00e9same), halva ou autre produit fait de graines de s\u00e9same, y compris le houmous fait maison<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Graines de chia enti\u00e8res\/moulues<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Graines de lin enti\u00e8res\/moulues<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres graines (p.\u00a0ex.\u00a0graines de tournesol, graines de pavot)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

ALIMENTS S\u00c9CH\u00c9S\/TRANSFORM\u00c9S OU AUTRES\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Farine de bl\u00e9 (p.\u00a0ex.\u00a0farine tout usage utilis\u00e9e pour la boulangerie, la cuisine, la p\u00e2te \u00e0 modeler)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Manger, go\u00fbter ou l\u00e9cher de la p\u00e2te ou une pr\u00e9paration crue ou non cuite faite avec de la farine de bl\u00e9 (p.\u00a0ex. p\u00e2te \u00e0 biscuits, pr\u00e9paration pour g\u00e2teau ou muffins)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout autre dessert ou p\u00e2tisserie non mentionn\u00e9e ailleurs (p. ex. g\u00e2teau au fromage, tartes, choux \u00e0 la cr\u00e8me, \u00e9clairs, mousses ou g\u00e2teaux).<\/p>\n

Si oui, pr\u00e9cisez\u00a0: __________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Substituts de viande \u00e0 base de plantes (p.\u00a0ex.\u00a0tofu, galettes ou hot-dogs v\u00e9g\u00e9tariens)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: __________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u00a0Tofu<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre substitut de viande \u00e0 base de plantes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fruits s\u00e9ch\u00e9s (p.\u00a0ex.\u00a0raisins, canneberges, abricots)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Barres granolas, barres \u00e9nerg\u00e9tiques ou autres barres prot\u00e9in\u00e9es<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Croustilles ou bretzels<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres collations pr\u00e9emball\u00e9es (p.\u00a0ex. craquelins, biscuits, petits g\u00e2teaux)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Chocolat ou friandises contenant du chocolat<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Aliments ou breuvages contenant du cannabis comme ingr\u00e9dient (ex. brownies ou autres p\u00e2tisseries, jujubes ou friandises, chocolat, huiles, th\u00e9s, jus ou boissons gazeuses, etc.).<\/p>\n

\u00a0Si oui, pr\u00e9cisez\u00a0: ______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

C\u00e9r\u00e9ales \u00e0 d\u00e9jeuner froides<\/p>\n

Si oui, pr\u00e9cisez\u00a0: _______________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

C\u00e9r\u00e9ales chaudes (p.\u00a0ex.\u00a0gruau, cr\u00e8me de bl\u00e9, flocons d\u2019avoine)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n\n
\n

Section\u00a011\u00a0: Donn\u00e9es d\u00e9mographiques<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Ma derni\u00e8re question concerne votre origine ethnique. Dans notre soci\u00e9t\u00e9, les personnes sont souvent d\u00e9crites en fonction de leur origine ethnique et se consid\u00e8rent comme \u00e9tant \u00ab\u00a0blanches\u00a0\u00bb ou \u00ab\u00a0noires\u00a0\u00bb ou \u00ab\u00a0sud-asiatiques\u00a0\u00bb, par exemple. Cette information est recueillie afin de mieux comprendre la personne infect\u00e9e par E. coli<\/em> dans le but d\u2019orienter notre enqu\u00eate.<\/p>\n

(Note \u00e0 l\u2019intention de l\u2019intervieweur\u00a0: si le cas n\u2019est pas \u00e0 l\u2019aise de r\u00e9pondre, passez la question)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Quelle cat\u00e9gorie ethnique vous d\u00e9crit le mieux? S\u00e9lectionnez toutes les r\u00e9ponses applicables\u00a0:<\/p>\n

\u2610Noire (p.\u00a0ex. africaine, afro-carib\u00e9enne, canadienne d\u2019origine africaine)<\/p>\n

\u2610Asiatique de l\u2019Est ou du Sud-Est (p.\u00a0ex.\u00a0chinoise, cor\u00e9enne, japonaise, ta\u00efwanaise, philippines, vietnamienne, cambodgienne, tha\u00eflandaise, indon\u00e9sienne, autre origine asiatique du Sud-Est)<\/p>\n

\u2610 Autochtones (p.\u00a0ex. Premi\u00e8res Nations, Inuit, M\u00e9tis)\u00a0:\u00a0\u00a0\u00a0 \u2610 Premi\u00e8res Nations \u2610 Inuit \u2610 M\u00e9tis<\/p>\n

\u2610 Latine (p.\u00a0ex. Am\u00e9rique latine, origine hispanique)<\/p>\n

\u2610 Moyen-orientale (p.\u00a0ex. arabe, perse, origine asiatique de l\u2019Ouest \u2013 par exemple, afghane, \u00e9gyptienne, iranienne, libanaise, turque, kurde)<\/p>\n

\u2610 Sud-asiatique (p. ex. origine sud-asiatique, par exemple, indienne de l\u2019Est, pakistanaise, bangladaise, sri-lankaise, indo-carib\u00e9enne)<\/p>\n

\u2610 Blanche (p.\u00a0ex. origine europ\u00e9enne)<\/p>\n

\u2610 Autre groupe (pr\u00e9cisez)\u00a0: _________________________<\/p>\n

\u2610 Incertain\/pr\u00e9f\u00e8re ne pas r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Notes\/Commentaires g\u00e9n\u00e9raux :<\/h2>\n

T\u00e9l\u00e9charger le format de rechange<\/a><\/p>\n

\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"

T\u00e9l\u00e9charger le format de rechange Contexte du questionnaire pour l’intervieweur Ce questionnaire est con\u00e7u pour recueillir des renseignements complets sur les facteurs de risque possibles li\u00e9s \u00e0 l’E. coli.\u00a0 Il est con\u00e7u pour des enqu\u00eates sur la grappe et l’\u00e9closion o\u00f9 la source d’infection est inconnue et o\u00f9 le questionnaire pourrait servir \u00e0 \u00e9tudier des […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":417,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"fullpage.php","meta":{"footnotes":""},"class_list":["post-2622","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2622","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/comments?post=2622"}],"version-history":[{"count":60,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2622\/revisions"}],"predecessor-version":[{"id":6346,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2622\/revisions\/6346"}],"up":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/417"}],"wp:attachment":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/media?parent=2622"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}