Anonymous

Food Allergy Form

A food allergy form is a documentation of a person’s special dietary needs. It involves a record of food allergies and intolerance. Use this checklist to ensure proper dietary needs are provided for the participant with food allergy or intolerance. DISCLAIMER: This checklist is created for a school setting, you can customize this checklist according to your nature of use.

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Title Page

Ambassador's full name

Food Allergy Form

Food Allergy / Intolerances

Food Allergy
- Dairy
- Soy
- Eggs
- Peanuts
- Tree Nuts
- Fish
- Shellfish
- Sesame
- Corn
- Wheat
- Others
- No allergies
Please specify. In case of none please answer N/A
Intolerances
- Gluten
- Lactose
- Fructans
- Salicylates
- Fructose
- Tyramine
- Polyols
- Sulfites
- Galactans
- Citric acid
- Histamines
- Fava Beans
- Nightshades
- Nitrites
- MSG
- Others
- No intolerances
Please specify
Other special diet needs or restrictions (i.e., Diabetes, IBS, other). If none please discard this question

THANK YOU!

Anonymous

Food Allergy Form

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.