Food Allergy Form

• Facility Name

• Student Name

• Prepared by

• Date

  Date

• Take or Attach Picture of Student

  Media

• Age

• Birth Date

  Date

• Student's Parent or Guardian Name

• Relationship to Student

• Parent's Contact No. (Work)

• Parent's Contact No. (Home)

• Email

Food Allergy / Intolerances

• Food Allergy

  Select Dairy Soy Eggs Peanuts Tree Nuts Fish Shellfish Sesame Corn Wheat Others

  • Dairy
  • Soy
  • Eggs
  • Peanuts
  • Tree Nuts
  • Fish
  • Shellfish
  • Sesame
  • Corn
  • Wheat
  • Others

• Please specify

• Intolerances

  Select Gluten Lactose Fructans Salicylates Fructose Tyramine Polyols Sulfites Galactans Citric acid Histamines Fava Beans Nightshades Nitrites MSG Others

  • Gluten
  • Lactose
  • Fructans
  • Salicylates
  • Fructose
  • Tyramine
  • Polyols
  • Sulfites
  • Galactans
  • Citric acid
  • Histamines
  • Fava Beans
  • Nightshades
  • Nitrites
  • MSG
  • Others

• Please specify

• Other special diet needs or restrictions (i.e., Diabetes, IBS, other)

Dietary Needs Questionnaire

• Please answer the following questions to better help us with your needs:

• What are the preferred food substitutions, if any? (e.g., soy butter for peanut butter, gluten-free bread, soy milk, etc):

• What types of contact will cause a reaction?

  Airborne

  Trace cross contact

  Actual ingestion of food

• Please explain

• Does the Student understand the food allergy and what needs to be done to manage it?

Completion

• By signing this I am certifying I understand the disclaimers contained in this form and I verify the information provided is true and correct.
  

• Parent/Guardian Signature

  Sign