Dietary Restrictions Survey
Basic Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
🥗 Diet Type
Do you follow a specific diet?
No restrictions
Vegetarian
Vegan
Pescatarian
Halal
Kosher
Keto
Paleo
Other
Any special nutritional requirements? (e.g., high protein, low sodium)
Which foods do you avoid?
Gluten
Dairy
Eggs
Nuts
Soy
Shellfish
Fish
Sesame
Other
🚫 Food Restrictions / Allergies
Do you have any food allergies?
Yes
No
Select food(s) you're allergic to
Gluten
Dairy
Eggs
Nuts
Soy
Shellfish
Fish
Sesame
Other
Select any symptoms that present with your food allergies.
Hives or skin rash
Itching (skin, mouth, or throat)
Swelling of lips, face, tongue, or throat
Difficulty breathing
Wheezing
Nasal congestion or runny nose
Sneezing
Coughing
Nausea
Vomiting
Diarrhea
Stomach cramps or abdominal pain
Dizziness or lightheadedness
Fainting or loss of consciousness
Rapid or weak pulse
Anaphylaxis (severe allergic reaction)
Other
How severe are your dietary restrictions?
Mild preference
Moderate intolerance
Severe allergy
Do you require strict cross-contamination prevention?
Yes
No
Do you carry emergency medication (e.g., EpiPen)?
Should staff be aware of emergency procedures?
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cultural / Religious Considerations
Any religious or cultural dietary rules?
Are there specific preparation requirements? (e.g., halal-certified, kosher kitchen)
Submit
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