Food Allergy Questionnaire
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent / Guardian Name
First Name
Last Name
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Allergy Details
Do you have any diagnosed food allergies?
Yes
No
Which food(s) are you allergic to?a question
Peanuts
Tree nuts
Milk / Dairy
Eggs
Wheat
Soy
Fish
Shellfish
Sesame
Other
What symptoms do you experience during an allergic reaction?
Hives / rash
Swelling of lips, tongue, or throat
Trouble breathing
Wheezing
Vomiting
Diarrhea
Stomach pain
Dizziness / fainting
Anaphylaxis
Other
When was the allergy first identified?
Less than 1 year ago
1–3 years ago
More than 3 years ago
Not sure
How severe are your reactions usually?
Mild
Moderate
Severe
Varies
Have you ever had an anaphylactic reaction?
Yes
No
Do you carry an epinephrine auto-injector (EpiPen or similar)?
Yes
No
Have you been prescribed any allergy medications?
Yes
No
If yes, please specify____
Do family members/caregivers know how to respond to a reaction?
Yes
No
Exposure and Prevention
Do you read ingredient labels before eating packaged foods?
Always
Often
Sometimes
Never
Are you concerned about cross-contact / cross-contamination?
Yes
No
Do you avoid eating at certain restaurants or events because of your allergy?
Yes
No
Sometimes
Please describe any other allergies or medical conditions:
Submit
Should be Empty: