School Cafeteria Intolerance Assessment Form
Use this form to assess cafeteria food intolerances, identify likely triggers, and review meal support needs for a student.
Student and Household Details
Student full name
*
First Name
Middle Name
Last Name
Grade / class
*
Please Select
Pre-K
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Other
Parent / guardian name
*
First Name
Middle Name
Last Name
Relationship to student
*
Parent
Guardian
Caregiver
Other
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
*
Phone
Email
Either
Intolerance Overview
Primary Concern Type
*
Food intolerance
Food allergy concern
Sensitivity
Digestive issue after meals
Other
When First Noticed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How Often It Happens
*
Never
Rarely
Sometimes
Often
Always
Typical Reaction Severity
*
1
2
3
4
5
Trigger Foods and Ingredients
Suspected trigger foods and ingredients
*
Milk/Dairy
Eggs
Wheat/Gluten
Soy
Peanuts
Tree Nuts
Sesame
Fish
Shellfish
Corn
Spicy Foods
Fried Foods
Sauces/Seasonings
Specific Menu Items
Other
Specific menu items or cafeteria foods that may trigger symptoms
Other suspected triggers
Symptoms and Timing
Symptoms experienced after eating
*
Stomach pain
Nausea
Vomiting
Bloating
Diarrhea
Constipation
Skin rash
Itching
Headache
Fatigue
Breathing discomfort
Other
When symptoms usually start after eating
*
During meal
Within 30 minutes
1–2 hours
Later the same day
Next day
How long symptoms usually last
Current Dietary Needs and Medical Guidance
Existing Dietary Restrictions
Vegetarian
Vegan
Dairy-free
Egg-free
Gluten-free
Nut-free
Halal
Kosher
Low-sugar
Other
Doctor-Recommended Meal Plan or Dietary Note on File
*
Yes
No
School Has Accommodation Instructions on File
*
Yes
No
Safe Foods, Ingredients to Avoid, or Foods to Prioritize
Cafeteria Meal History and Accommodation Needs
Does the student currently eat school cafeteria meals?
*
Yes
No
Sometimes
Which meal periods are affected?
*
Breakfast
Lunch
Snack
After-school meal
Other
Which cafeteria accommodations have been tried before?
Ingredient substitution
Separate serving
Alternate menu item
Packed meal from home
None
Other
How well did previous accommodations work?
1
2
3
4
5
What support is being requested now?
*
Ingredient substitution
Separate serving
Alternate menu item
Meal timing adjustment
Staff review of ingredients
Other
Safe Alternatives and Notes
Preferred safe meal alternatives or acceptable substitutions
Foods the student can reliably eat without issue
Cross-contact or preparation concerns for cafeteria service
Additional comments
Submit Assessment
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